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College  of  l^f^p^itimi  anb  ^urgeoitjsi 


Hihvavv 


STUDIES    IN 


Neurological  Diagnosis 


By 


JAMES    J.    PUTNAM,     M.D. 

AND 

GEORGE  A.  WATERMAN,  M.D. 


BOSTON 
Geo.  H.  Ellis  Co.,  Printers,  272  Congress  Street 

1909 


Copyright,  1902 

BY 

James  J.  Putnam,  M.D.,  and  George  A.  Waterman,  M.D. 


INDEX  OF  CASES. 


NO.  OF  CASE 
I. 

II. 
III. 

IV. 

V. 

VI. 
VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 
XVI. 

XVII. 

XVIII. 

XIX. 

XX. 


XXI. 

XXII. 

XXIII. 

XXIV. 


PACK 

Paralysis  of  the  Extensors  of  Hand  and  Fingers, 

of  Sudden  Onset 7 

Injury  of  Ulnar  Nerve  at  the  Wrist 7 

Complete    Paralysis   of    Whole    Arm,  of    Sudden 

Onset 9 

Paralysis  of    Flexors   and  Extensors   of    Fingers, 

without  Atrophy.     Recovery 9 

"Wrist-drop" ^o 

"Wrist-drop" i^ 

Injury  of  Brachial  Plexus  from  Forcible  Abduction 

of  the  Arm i  * 

Facial  Palsy ^^ 

Facial  Palsy '3 

Facial  Palsy I4 

Facial  Palsy ^4 

Facial  Palsy •     •     •  ^4 

Facial  Palsy ^S 

Severe  Pain,  with  Herpetic  Eruption,  over  the  Left 

Frontal  Area '5 

Ptosis,  due  to  Spasm  of  the  Orbicularis  Oculi    .     .  i6 
Facial  Palsy,  preceded  by  Convulsions  of  Face  and 

Arms '7 

Facial  Palsy ;  Herpes  of  Face  and  Neck  ....  17 

Supra -orbital  Neuralgia  of  Migrainoid  Type  .     .     .  19 
Severe  Frontal  Pain  of  Chronic  Course,  relieved  by 

Operation ^9 

Pain  in  thQ  Distribution  of  the  Ophthalmic  Division 
of  the   Fifth    Nerve,   recurring  Daily   at   the 

Same  Hour 20 

Facial  Neuralgia 21 

Intercostal  Neuralgia 22 

Intercostal  Neuralgia 22 

Severe  Neuralgic  Pain  over  the  Back  of  the  Head 

on  the  Left  Side        23 


IV 


KO.  OF   CASE 

XXV. 


XXVI. 
XXVII. 

XXVIII. 

XXIX. 


XXX. 


XXXI. 

XXXII. 

XXXIII. 


XXXIV. 

XXXV. 

XXXVI. 

XXXVII. 

XXXVIII. 

XXXIX. 
XL. 


XLI. 

XLII. 

XLIII. 

XLIV. 

XLV. 

XLVI. 

XLVII. 

XLVIII. 


Almost  Constant  Pain  in  the  Back  of  the  Neck,  on 
the  Left  Side,  of  long  Duration ;  also,  Pain  on 

the  Right  Side  of  the  Face 23 

Intense  Pain  in  the  Left  Side 24 

Neuralgic    Pain  of    Burning   Character  in    Right 

Hand  and  Arm 25 

Wide-spread  Atrophic  Paralysis,  of  Acute  Onset,  in 

a  Young  Child  ;  associated  at  first  with  Fever,       26 
Wide-spread  Muscular  Paralysis  and  Atrophy,  of 
Acute   Onset,  associated   at  first  with  severe 

Pain 27 

Rapid  Loss  of  Power  in  Arms  and  Legs,  followed 
by  Wide-spread  Muscular  Wasting ;  later, 
almost  Complete  Recovery  in  Legs  and  Im- 
provement in  Arms.     No  Disorder  of  Sensi- 

biUty 28 

Wide-spread  Paralysis  and  Atrophy  of  the  Limb 

Muscles,  of  Acute  Onset,  with  Fever      ...       29 
Partial  Paralysis  of  all  Four  Limbs,  resulting  from 

a  Fall  on  the  Head       31 

"  Numbness "  and  Weakness  of  Arms  and  Legs, 
with  General  Nervous  Symptoms,  following  a 

Blow  on  the  Head 32 

Paralysis  and  Atrophy  of  the  Arm ;  Erb's  Type     .       ^3 
Paralysis  of  the  Left  Arm ;  Erb's  Type     ....       34 

Pain  m  the  Arm  of  Long  Standing 35 

Pain  in  the  Right  Arm  and  Other  Symptoms     .     .       36 
Neuralgic  Pain  in  Arms ;  Paraplegia,  remitting  and 

exacerbating  by  Turns 37 

Pain  in  a  Definite  Area  of  one  Arm 38 

Injury  in  Cervical  Region ;  Paresis  of  Limbs  and 
Other  Serious  Symptoms ;    Sudden  Improve- 
ment at  the  End  of  Fifteen  Months        ...       42 
Entire  Paralysis  of  the  Legs,  etc.,  of  Sudden  On- 
set, following  Injury 45 

Paraplegia  of  the  Legs  and  Many  Other  Ner- 
vous Symptoms,  following  a  Slight  Accident  .       46 

Paraplegia 48 

Paraplegia  of  Acute  Onset,  in  an  Elderly  Lady       .       49 

Progressive  Paraplegia  :  Recovery 50 

Paraplegia  of  Sensation  and  Motion 52 

Paraplegia  of  Legs  after  a  Fall 52 

Spastic  Rigidity  of  the  Legs,  of  Gradual  Onset .     .       57 


V 


NO.  OF   CASK 

XLIX. 


LI. 

LII. 

LIII. 

LIV. 

LV. 

LVI. 


LVII. 
LVI  II. 

LIX. 


LX. 

LXI. 

LXII. 

LXIII. 

LXIV. 

LXV. 


Increasing   Weakness   of    Both    Legs,    associated 

with  Paraesthesia  and  Sense  of  Coldness      .     .       58 

Pain  in  Left  Side  and  Groin,  gradually  increasing, 
and  made  worse  by  Motion.  Gradual  Impair- 
ment of  Use  of  Legs,  with  Disturbance  of 
Sensibility  and  Exaggerated  Tendon-Reflexes,       59 

Severe  Pain  around  the  Body,  increased  by  Move- 
ment ;  Paraplegia  of  Gradual  Increase  ;  Death,       60 

Spasm   of   Muscles  about   Hip,  following  Injury. 

Hemi-anaesthesia 62 

Pain  along  the  Course  of  the  Sciatic  Nerve,  asso- 
ciated with  Scoliosis  and  Muscular  Spasm  .     .       62 

Paralysis  of  Sphincters,  with  Impairment  of  Sensi- 
bility in  the  "  Saddle  Back "  Areas  of  the 
Thighs 63 

Pain  in  the  Left  Leg  and  Foot,  following,  in  Gen- 
eral, the  Course  of  the  Sciatic  Nerve ;  Later, 
Paraesthesia  and  Loss  of  Power 65 

Severe  Pain  on  the  Posterior  Surface  of  the  Left 
Leg  from  the  Buttock  to  the  Foot  ;  also, 
Some  Pain  on  the  Front  Surface  of  Right 
Leg  and  across  the  Lower  Part  of  the  Back  66 

Pain  in  the  Back  and  Sciatic  Areas 67 

Pain   about  the  Waist   and  in  the  Back ;    Great 

Nervous  Excitability 68 

Pain,  followed  by  Atrophy  and  Impairment  of 
Sensibility,  in  the  Areas  of  Distribution  of 
Both  Anterior  Crural  Nerves 70 

Tendency  to  the  Occurrence  of  Severe  Hyperaesthe- 
sia  of  the  Anterior  Surface  of  the  Left  Thigh, 
making  Locomotion  Painful  and  Difficult    .     .       71 

"  Toe-drop  "  of  the  Right  Foot,  of  rather  Sudden 

Onset 72 

Gradual   Loss   of    Power  in    Both   Legs,   causing 

"  Toe-drop  " 73 

Wasting  and  Weakness  of  the  Extensor  Muscles 

of  the  Left  Thigh -j^ 

Spastic  Equino-varus,  with  Impairment  of  the 
Sensibility  of  Foot  and  Leg ;  Serious  Impair- 
ment of  Nutrition;  High  Degree  of  Nervous 
Weakness,  following  Moderate  Injury     ...       74 

Double  Vision,  Neuralgic  Pains  in  Legs,  Numb- 
ness of  Hands,  Impairment  of  Speech     ...       75 


VI 

NO.  OF   CASE  PAGE 

LXVI.  Deep-seated,  Distressing  Pain  in  the  Left  Flank, 
increased  by  Motion ;  Depression  and  De- 
bility   77 

LXVII.     Severe  Fits  of  Coughing  and  Choking,  Attacks  of 
Vomiting,    Pains    of    Intense    Severity,   and 

Other  Symptoms 78 

LXVIII.     Paroxysmal  Attacks  of  Epigastric  Pain     ....       80 
LXIX.     Atrophy  and  Pain  in  Hands  and  Arms;  very  Slow 

Progression ;  Death  from  Intercurrent  Disease,       81 
LXX.     Staggering   Gait,   Nystagmus,  Hesitating   Speech, 

Clubbed  Foot 82 

LXXI.     Recurrent  Attacks  of  Vomiting 83 

LXXII.     Diarrhoea  of  Long  Standing,  Paraesthesia  of  All 

Four  Extremities 84 

LXXIII.     Paraplegic  Weakness  and  Inco -ordination     ...       86 
LXXIV.     Paraesthesia    of    Legs,     In  co-ordination.    Chronic 

Diarrhoea,  Glycosuria        87 

LXXV.     Paraesthesia  of  All  Four  Extremities.   Increased  Re- 
flexes.   Muscular  Atrophy  of  Hahds  and  Arms,       89 
LXXVI.     Recurrent  Paraesthesia  of  Both  Hands,  associated 

with  Pain 89 

LXX VII.     Tremor  of  Arm  and  Head,  associated  vrith  Anaes- 
thesia of  Hand 90 

LXXVIII.     Inco-ordination  of  Limbs  and  of  Speech  Muscles 

following  Malaria 92 

LXXIX.     Spastic   Paralysis  and  Ataxia,  of  Gradual  Onset; 

with  Bulbar  Symptoms 92 

LXXX.     Weakness  and  Inco-ordination  of  Limbs,  of  Acute 

Onset ;  Severe  Anaemia 94 

LXXXI.     Paraesthesia,  Progressive  Weakness  and  Ataxia,  in- 
volving all  Four  Limbs  and   ending  fatally; 

High  Degree  of  Anaemia 95 

LXXXII.     Progressive  Paraesthesia  and  Weakness  of  Limbs  ; 

with  Exhausting  Illness 97 

LXXXIII.     Paroxysms    of   Abdominal   Pain;    Paralysis    arvd 
Atrophy  of  Certain  Groups  of  Muscles  of  Arms 

and  Legs 99 

LXXXIV.     Progressive  Paraesthesia  and  Loss  of  Power,  result- 
ing in  Paralysis  of  Respiratory  Muscles        .     .     100 
LXXXV.     Progressive,  Spreading  Paralysis ;  Death  ....     102 
LXXXVI.     Numbness,  Weakness,  and  Atrophy  of  Arms  and 
Legs,  with  Atrophy;  Improvement  to  a  Cer- 
tain Point  only,  then  New  Symptoms      .     .     .     103 


Vll 

NO.  OF   CASE  PAGE 

LXXXVII.  Pain,  Impairment  of  Sensibility,  Paralysis  and 
Atrophy,  of  the  Muscles  of  Arms  and  Legs, 
especially  those  below  the  Elbows  and  Knees ; 

Cerebral  Complications 104 

LXXXVIII.    "  Numbness,"    Soreness,   and  Weakness  of  Arms 

and  Legs,  after  Typhoid 105 

LXXXIX.     Weakness  of  Arms  and  Legs  with  Extensive  Paraes- 

thesia io6 

XC.     Diffuse  Paralyses  of  Sensation  and  Motion  of  Long 

Duration ;  nearly  Complete  Recovery     .     .     .     108 
XCI.     Delirium,  Mental  Confusion,  Extensor  Paralysis  of 

Extremities no 

XCI  I.     Progressive  Atrophy  of  All  the  External  Muscles  of 

the  Body 112 

XCIII.     Gradually  Progressive  Muscular  Wasting,  begin- 
ning in  the  Hands    113 

XCIV.     Progressive  Loss  of  Muscular  Power,  gradually  in- 
volving almost  all  the  Muscles  of  the  Body ; 

very  Chronic  Course 114 

XCV.     Numbness    of   Hands   and  Arms,  with   Muscular 
Wasting  and  Trophic    Lesions  of  the  Skin ; 

Peculiar  Changes  in  Sensibility 115 

XCVI.     Atrophy  of  Muscles  surrounding  Shoulder     .     .     .     ii8- 
XCVII.     Weakness  of  the   Muscles  of    Forearm,  especially 

the  Extensors 119 

XCVIII.     Diffuse,    Progressive    Muscular    Weakness,    with 

Trophic  Changes 120 

XCIX.     Wide-spread  and  Progressive  Muscular  Weakness, 
with  Nutritional  Muscular  Changes,  in  a  Boy  of 
Ten.     Older  Brother  similarly  affected  .     .     .     122 
C.     Paresis  of  External  and  Internal  Eye  Muscles ;  Some 

Difficulty  in  Use  of  Limbs 123 

CI.     Severe  Headache,  with   Paralysis  of   Certain  Eye 

Muscles 124 

CII.     Progressive  Difficulty  in  Talking  and  Swallowing; 

eventually  some  Involvement  of  Limbs       .     .     125 
cm.     Difficulty  in  Speech  and  Swallowing,  and  to  Some 
Extent  in  the  Use  of  the  Extremities;    Con- 
genital     126 

CIV.     Attacks  of  Weakness  of  All  the  Muscles  of  the 

Body,  ending  fatally 128 

CV.  Sudden  Attack  of  Severe  Dizziness  with  Pain  in 
Face  and  Tongue  ;  Facial  Palsy,  and  Paralysis 
of  Certain  Eye  Muscles 132 


KO.  OF   CASE 

CVI. 


evil. 


CVIII. 


CIX. 

ex. 


CXI. 


CXII. 


CXIII. 
CXIV. 

exv. 


exvi. 

exvii. 

cxviii. 


cxix. 
cxx. 

exxi. 

exxii. 


Vlll 

PAGB 

Intense  Headache;  Increasing  Stupor;  Irregular 
eonvulsive  Movements  of  All  Extremities,  of 
Slight  Degree :  Death 133 

eonvulsions  of  the  Right  Arm  and  Leg  and  Right 
Side  of  the  Face,  leading  to  Hemiplegia,  with 
Involvement  of  the  Arm  much  more  than  the 
Leg 134 

Injury  to  Head,  followed  by  Headache,  Vomit- 
ing, gradually  deepening  Impairment  of  Con- 
sciousness,  Convulsions :  Eventual  Recovery    .     136 

Hemiplegia  of  Unusual  Form  and  Onset  ....     137 

Wide-spread  Paralysis  with  Unconsciousness,  fol- 
lowing an  Acute  Infectious  Disease.  Partial 
Recovery;    Mental  Deterioration  .....     139 

Temporary  Paralysis  of  Arms  and  Legs,  of  Acute 
Onset,  with  Disturbance  of  Sensibility.  Im- 
provement, followed  by  Headache  and  Con- 
vulsion.    Recovery 140 

Acute,  Severe  Headache  in  a  Young  Person,  fol- 
lowed by  Unconsciousness  without  Further 
Symptoms,  and  ending  fatally 141 

Headache ;  Pallor,  without  Discoverable  Changes 

in  the  Blood 142 

Headache 143 

Very  Gradual  Loss  of  Consciousness,  with  Pain  in 
the  Head,  following  a  Slight  Injury.  Eventual 
Recovery 144 

Headache 145 

Persistent  Occipital  Headache      ......     146 

Injury  with  Unconsciousness ;  Improvement,  then 
Relapse ;  Fever  and  Muscular  Rigidity : 
Death 147 

Convulsions  of  the  Left  Side,  recurring  regularly 
in  an  Elderly  Patient  recovering  from  Influ- 
enza, and  resulting  in  Hemiplegia       .     .     .     .     148 

Attacks,  at  Different  Periods,  of  Transient  Hemi- 
plegia with  Aphasia  ;  Paraplegia  with  Crossed 
Paralysis  of  Sensation,  Motion,  etc.  Improve- 
ment under  Treatment 149 

Complete  Paralysis  of  Acute  Onset,  with  Universal 

Rigidity 150 

Convulsive  Seizures ;  Attacks  of  Unconsciousness 

with  Automatic  Movements 151 


IX 

NO.  OF    CASE  PAGE 

CXXIII.     Attacks  of  Temporary  Alteration  of  Consciousness, 

recurring  repeatedly  in  the  Same  Form  .     .     .     152 
CXXIV.     Attacks  of  Unconsciousness  and  Convulsions    .     .     154 
CXXV.     Epileptiform  Seizures  of  Peculiar  Character       .     .     155 
CXXVI.     Periods  of  Unconsciousness,  and  Other  Attacks  of 

Peculiar  Sort 156 

CXXVII.     Eccentric  and  Violent  Disposition;  Prolonged  Un- 
consciousness, with  Temporary  Paralysis  and 

Altered  Reflexes :  Recovery 157 

CXXVIII.     Right  Ophthalmoplegia,  Left  Hemi-anaesthesia  and 

Hemiparesis 160 

CXXIX.     Transitory   Hemiplegia  during  Typhoid ;  followed 
by  Attacks  of  Paraesthesia  in  the  Left  Hand 
and  occasionally  Loss  of  Consciousness      .     .     161 
CXXX.     Gastric  Symptoms ;  Vertigo;  Morbid  Fear    .     .     .     162 

CXXXL     Occasional  Fainting  Spells       164 

CXXXII.     Epileptiform  Seizures  ;  Slight  Mental  Defect  (?)     .     165 

CXXXIII.     Vertigo  with  Ear  Disease 166 

CXXXIV.     Dizziness  and  Hemi-paraesthesia,  of  Sudden  Onset     167 

CXXXV.     Vertigo 168 

CXXX VI.     Vertiginoid  Attacks 169 

CXXXVII.  Sudden  Attack  of  Convulsion  of  the  Right  Arm  and 
Leg,  lasting  Half  an  Hour  or  More,  and  ter- 
minating in  Partial  Hemiplegia       170 

CXXXVIII.     Paroxysmal    Vertigo    and    Attacks    of     Unusual 

Form,  with  Loss  of  Consciousness     .     .     .     .     171 

CXXXIX.     Headache 172 

CXL.     Recurrent   Attacks   of    Numbness   of    the    Right 
Hand,  and  Convulsions  of  the  Hand,  Arm,  and 

Face.     Operation 174 

CXLL     Recurrent  Attacks  of  Disturbance  of  Speech,  asso- 
ciated with  Numbness  of  the  Right  Arm,  and 

Headache 176 

CXLIL     Temporary  Attacks  of  Hemi-anaesthesia    ....     177 
CXLIIL     Pain  in  Head,  Dizziness,  Nausea,  and  Vomiting; 

Unsteady  Gait 178 

CXLIV.     Headache,  Vomiting,  Optic  Neuritis 179 

CXLV.     Neurasthenia  with  Vaso-motor  Symptoms      .     .     .     iSo 
CXLVL     General  Neurasthenic  Symptoms,  associated  with 

Convulsive  Attacks  ending  fatally       ....     181 
CXLVII.'    Nervous  Symptoms,  with  Attacks  of  Mental  Dis- 
tress and  Physical  Emotion -signs 184 

CXLVni.     General    Nervousnes.s,    associated  with    a   sort   of 

Tic 186 


X 

NO.  OF   CASE  PAGE 

CXLIX.     Diffuse  Muscular  Rigidity,  lasting  Some   Weeks 

and  passing  away  slowly i88 

CL.     Tendency    to     Spasms    of    the    Diaphragm    and 
Limbs,   occurring  under    Special    Conditions. 

Recovery 189 

CLI.     Hemi-anassthesia  of    Sudden   Onset,  with    Partial 

Hemiplegia 191 

CLII.     Involuntary   Movements    of   the  Head  and  Face,     191 
CLIII.     Tendency  to  fall  to  the  Ground  when  Startled,  with 

Alteration  or  Loss  of  Consciousness       .     .     .     192 
CLIV.     Constant  Involuntary  Movements  affecting  all  the 
External    Muscles  of  the  Body,  beginning  in 
Infancy    and     remaining    without     Material 

Change  through  Life        194 

CLV.     Double  Athetosis   ^ 195 

CLVL     Weakness    from    Birth,   Convulsions;    Increasing 

Rigidity  of  the  Legs 196 

CLVIL     Morbid  Ideas 198 

CLVIII.     Syphilitic  Infection,  followed  by  Symptoms  of  very 

General  Character 199 

CLIX.     Morbid  Fears 200 

CLX.     Paralysis  of  Eye  Muscles ;  Mental  Failure.    Death,     201 
CLXI.     Cerebral    Symptoms    of   Acute    Onset,  indicating 

rather  Widespread  Disturbance 202 

CLXIL     Symptoms  suggesting  General  Paralysis  in  a  Patient 

with  Tumor  of  the  Corpus  Cullosum       .     .     .     203 
CLXIIL     Attack  of  Epileptic  Character,  terminating  rather 
unexpectedly  by  Rapid  Improvement  and  Re- 
covery   206 

CLXIV.     Blueness  of  Fingers,  with  Gangrene 207 

CLXV.     Pain  in  Hand  and  Arm,  with  Trophic  and  Vascular 

Changes  in  the  Fingers 208 

CLXVI.     Hypertrophy  of  the  Head,  Face,  and  Extremities,     209 

CLXVII.     Deep,  Indolent  Ulcer  of  the  Toe 210 

CLXVIII.     Peculiar  Abnormality  of  Development.     Improve- 
ment under  Treatment 211 

CLXIX.     Debility,  with  a  Pecfuliar  Change  in  Nutrition,  com- 
ing on  at  the  Period  of  the  Menopause   .     .     .     212 
CLXX.     Backward    Mental    and    Physical     Development. 

Numerous  Stigmata  of  Degeneration      .     .     .     213 


PREFACE. 


During  the  course  of  the  past  few  years  certain  special 
experiments  have  been  made  for  the  purpose  of  securing  the 
best  methods  of  giving  the  third-year  students  a  reasonable 
knowledge  of  neurology  in  the  shortest  possible  time.  Fort- 
unately, that  task  has  itself  grown  easier,  of  late  years,  for 
the  reason  that  the  importance  of  the  subject  has  come  to 
be  better  recognized  by  the  profession  and  the  students,  and 
its  closer  study  is  approached  with  livelier  interest.  The 
teachers  realize  that  this  change  of  sentiment  calls  for  fresh 
effort  on  their  part,  but  they  wish  the  students  to  realize  in 
their  turn  that  the  teachers'  duty  consists  only  in  showing 
how  study  and  observation  can  be  made  effective,  not  how 
they  can  be  dispensed  with  or  abridged.  The  work  of  the 
class-room  must  be  supplemented  by  work  at  home. 

The  neurological  department  of  the  Massachusetts  Gen- 
eral Hospital  is  very  rich  in  interesting  and  important  cases ; 
and  the  plan  of  teaching  first  followed  was  to  demonstrate 
large  numbers  of  patients,  the  students  being  urged  to  ask 
and  answer  questions  concerning  them.  But,  while  this 
method  interested  the  abler  and  more  ambitious  men,  it  was 
not  systematic  enough  for  the  whole  number,  and,  conse- 
quently, about  four  years  ago,  the  plan  was  tried  of  supple- 
menting the  demonstrations  by  a  systematic  quiz,  based  on 
the  study  of  successive  chapters  of  an  accepted  text-book. 
Printed  lists  of  questions  were  also  given  out  for  the  sake  of 
calling  attention  to  important  points. 

This  plan  found  favor  with  the  students,  and  might  have 
been  continued  longer  but  for  the  fact  that  the  present 
method,  which  was  first  definitely  suggested  by  Dr.  W.  B. 


Cannon,*  in  January,  1900,  commended  itself  as  preferablec 
Dr.  Cannon  called  attention  to  the  success  which  had  at- 
tended the  "  case-system  "  of  instruction  in  the  Law  School, 
and  gave  reasons  for  believing  that  something  similar  could 
be  used  with  benefit  for  medical  teaching.  It  was,  of  course, 
obvious  from  the  first  that  there  were  distinct  differences 
between  the  needs  of  the  two  schools.  The  law  seeks  to 
base  itself  on  a  relatively  small  number  of  precedents ;  while 
medicine  progresses  by  the  accumulation  and  comparison 
of  large  numbers  of  observations,  differing,  perhaps,  but 
slightly  from  one  another.  Nevertheless,  inasmuch  as  it  is 
impossible  to  give  each  student  a  chance  to  observe  great 
numbers  of  patients  with  due  care  and  under  due  supervi- 
sion, it  was  believed  that  this  plan  of  discussing  published 
cases,  given  out  beforehand,  possessed  certain  distinct  ad- 
vantages, and  afforded  a  means  of  supplementing  the  clinical 
work  which  was  of  greater  value  than  either  didactic  lectures 
or  quizzes, —  the  more  so  that,  throughout  his  professional 
life,  every  physician  is  called  upon  to  read  large  numbers  of 
cases  published  by  his  colleagues,  and  has  great  need  of 
skill  in  seizing  rapidly  their  salient  points. 

It  soon  became  evident,  however,  that,  if  the  case-system 
was  to  be  adopted  at  all,  it  should  be  adopted  exclusively. 
For,  if  text-book  recitations  were  to  be  made  an  integral  part 
of  the  instruction,  many  of  the  students  would  be  only  too 
glad  to  devote  their  energies  to  them  as  an  easy  means  of 
packing  the  memory  with  facts  learned  by  rote,  and  would 
fail  to  get  the  benefit  which  might  be  secured  by  a  thor- 
ough immersion  in  the  study  of  cases  of  disease. 

This  plan  has  now  been  in  use  for  three  years,  and  has 
been,  each  year,  more  rigorously  followed.  It  is  needless  to 
say  that  at  the  same  time  the  clinical  section-work  in  this 
department,  as  in  all  the  other  departments  of  the  school, 
has  been  systematized  and  increased  to  the  fullest  extent 
possible,  and  that  it  is  relied  upon  as  furnishing  by  far  the 
most  important  means  of  instruction,  so  far  as  it  goes. 

*  Boston  Medical  and  Surgical  Journal,  Jan.  ii  and  May  31,  1900. 


Every  one  who  has  employed  this  method  of  teaching  must 
have  found  himself  in  face  with  the  question,  On  what  basis 
should  the  cases  be  selected,  as  illustrating  the  commoner 
types  of  disease  or  as  affording  problems  for  study  ?  Expe- 
rience and  reflection  have  led  us  to  favor  the  latter  plan, 
though  not  to  entire  exclusion  of  the  former. 

To  illustrate  in  any  adequate  degree  even  the  simpler 
proposition  of  the  text  books,  by  any  such  system  as  this, 
would  be  as  impossible  as  it  is  unnecessary.  The  essential 
function  of  the  case-method  is  to  teach  the  students  to  think, 
to  analyze,  to  convert  pen-pictures  into  sense-pictures,  and 
to  utilize  their  books  as  works  of  reference.  In  pursuance 
of  this  idea  we  have  not  even  tried  to  select  simple  or  typ- 
ical cases  alone,  but,  rather,  cases  which  call  attention  to 
points  of  special  importance  as  regards  diagnosis.  In  study- 
ing and  discussing  these,  with  the  constant  aid  of  text-book 
descriptions,  the  "types,"  so  far  as  they  exist,  will,  we 
believe,  be  learned  incidentally  and  emphasized  by  contrast, 
and  the  student  will  be  trained  to  make,  as  it  were,  his  own 
text-book.  The  "  cases  "  are  intended  purely  as  an  aid  to 
the  study  of  the  living  problems  presented  in  actual  clinical 
work.  They  are  to  be  regarded  as  a  supplement  to  obser- 
vation, but  in  no  sense  as  a  substitute  for  it. 

The  value  of  this  method  must  always  depend  on  the  use 
that  is  made  of  it  by  the  teacher ;  but  any  fairly  well- 
equipped  student  can,  we  believe,  make  himself  a  master  of 
the  elements  of  neurology  if,  in  addition  to  doing  his  clinical 
work,  he  will  study  this  collection  of  cases,  take  part  in 
the  discussion  of  them  in  the  class-room,  and  read  his  text- 
books in  the  light  of  the  experience  thus  gained. 

These  histories  are  the  records  of  real  experiences,  and 
our  aim  has  been  to  write  them  out  in  such  a  way  as  to 
reproduce  the  impressions  originally  made  on  the  examiner, 
and  not  in  the  form  recommended  in  the  lectures  on  "case- 
taking." 


We  have  tried  to  make  it  possible  for  the  student  to  pict- 
ure to  himself  each  patient's  appearance  and  condition  at 
the  different  stages  of  the  examination,  and  to  consider  what 
provisional  diagnoses  would  have  suggested  themselves  to 
his  mind  as  the  interview  proceeded,  and  what  additional 
data  would  have  been  needed  for  justifying  either  one. 

Frequently,  a  positive  diagnosis  may  be  impossible;  but 
the  reasons  for  this  conclusion  should  then  be  clearly  recog- 
nized, as  well  as  the  different  possibilities  toward  which  the 
various  signs  and  symptoms  point. 

After  the  diagnosis  has  been  made,  two  further  tasks 
should  be  undertaken,  so  far  as  is  practicable.  First,  the 
complete  symptomatology  of  the  disease  which  is  assumed 
to  be  present  (as  recorded  in  a  good  handbook,  supplemented 
by  personal  observation)  should  be  rapidly  run  over,  in 
order  that  it  may  be  seen  what  symptoms  are  present  and 
what  symptoms  are  lacking,  in  the  given  case.  Next,  the 
features  peculiar  to  each  history  —  those  which  make  it  of 
especial  interest  —  should  receive  attention. 

In  analyzing  the  cases,  it  is  usually  best  to  begin  by  study- 
ing the  signs  which  point  to  the  localization  of  the  supposed 
lesions,  irrespective  of  the  clinical  diagnosis,  and,  next,  to 
consider  the  general  trend  of  the  symptoms  taken  as  a  whole, 
in  the  light  of  clinical  information,  inference,  and  experience. 
These  two  processes  of  investigation  imply  somewhat  differ- 
ent sorts  of  knowledge  and  preparation.  The  first  pre- 
supposes hardly  more  than  a  good  acquaintance  with  the 
anatomy  and  physiology  of  the  nervous  system ;  the  second 
cannot  be  followed  successfully  unless  the  examiner  has  ac- 
quired a  familiarity  with  a  variety  of  symptom-complexes, 
and  the  habit  of  recognizing  quickly  even  the  slighter  indi- 
cations of  the  various  diseases, —  their  complexion  and  ac- 
cent, as  one  might  say, —  just  as  one  recognizes  a  family 
likeness.  It  is  this  habit  that  constitutes  one  of  the  chief 
powers  of  the  skilful  diagnostician,  and  the  student  will  gain 
it  more  and  more  in  proportion  as  he  studies  larger  and 


5 

larger  numbers  of  patients  and  trains  himself  to  notice  the 
essential  features  of  the  different  disorders.  It  is  not  only 
the  conscious  recognition  of  the  fact  that  a  given  case  is 
essentially  like  or  essentially  unlike  other  cases  which  are 
recorded  in  memory  or  found  in  print,  that  must  be  trained 
and  satisfied,  but  also  the  instinct  of  similarity  and  dissimi- 
larity ;  and  it  must  be  remembered  that  the  very  existence 
and  correctness  of  this  trained  instinct  practically  means 
that  the  various  diseases  themselves  have  marks  which  are 
distinctive  and  yet  which  have  not  been  fully  classified  and 
described. 

Many  of  the  cases  in  this  series  are  designedly  given  in 
an  incomplete  form,  and  the  following  suggestions  are  offered 
as  an  aid  to  further  inquiry :  — 

1.  Among  the  difficulties  that  present  themselves  to  the 
student,  one  of  the  chief  is  that  of  distinguishing  between 
the  structural  and  the  functional  disorders, —  a  distinction 
of  fundamental  importance.  To  help  in  the  overcoming  of 
this  difficulty,  numerous  cases  of  a  "functional"  sort  have 
been  introduced  among  those  where  organic  or  structural 
lesions  were  present,  and  vice  versa.  The  student  is  urged 
never  to  commit  himself  to  a  diagnosis  without  having  con- 
sidered with  special  care  in  which  of  these  two  great  classes 
his  case  probably  belongs,  or  whether  it  may  not  belong  in 
both.  Not  infrequently  a  case  may  be  partly  "  functional " 
and  partly  "organic"  in  nature;  and  the  functional  ele- 
ment may  have  come  first,  the  organic  disease  only  as  a 
secondary  result.  On  the  other  hand,  even  where  an  or- 
ganic or  structural  lesion  is  the  main  cause  of  trouble,  the 
symptoms  may  not  be  distinctively  commensurate  with  the 
effects  of  the  lesion,  but  due,  rather,  to  a  neurosis  seconda- 
rily induced  (as  where  a  migraine  previously  "  latent ''  has 
been  brought  out  by  disease  of  the  eyes  or  nose). 

2.  It  is  impossible  to  overrate  the  importance  of  recog- 
nizing the  presence  of  a  neuropathic  tendency,  either  on  the 
part  of  the  patient  himself  or  on  that  of  other  members  of 


his  family.  To  arrive  at  a  conclusion  on  this  point,  it  is 
best  to  inquire,  first,  as  to  ^'■general  nervousness,^^  or  neurotic 
temperament ;  next,  as  to  special  organic  or  fiinctional  dis- 
eases of  the  nervous  system ;  third,  as  to  nutritional  disorders, 
as  tuberculosis,  arthritis,  diabetes,  and  the  other  constitu- 
tional diseases  with  which  the  affections  of  the  nervous  sys- 
tem are  so  often  associated. 

3.  The  existence  of  the  so-called  stigmata,  or  signs  of  lack 
of  development  or  disordered  development,  such  as  infan- 
tilism, peculiarities  of  the  skin  and  its  appendages,  of  the  ears, 
the  teeth,  the  palate,  etc.,  should  also  be  sought  after ;  and 
likewise  all  signs  of  failure  of  physiological  mechanisms,  as 
shown,  for  example,  in  squinting,  stammering,  choreiform  tics, 
morbid  motor  habits,  faulty  heart-innervation,  and  the  like. 
Even  diseases  which  are  apparently  confined  to  a  single 
nerve,  as  in  facial  palsy,  may  have  hidden  bonds  with  con- 
stitutional, neurosal,  or  nutritional  disorders,  the  presence  of 
which  might  be  suggested  or  accentuated  by  the  discovery 
of  *'  stigmata  "  such  as  these. 


^^M^^ 


djL^     A^iM^     y  tr^Jj^^ 


CASES. 


I. 


Paralysis  of  the  Extensors  of  Hand  and  Fingers^  of  Sudden 

0?tset. 

A  middle-aged  man,  of  alcoholic  habits,  waked  in  the 
morning,  after  having  been  on  a  debauch  the  previous  night, 
with  the  fingers  of  the  right  hand  weak  and  "  numb  "  (pares- 
thetic). It  was  impossible  to  extend  the  carpus  or  the 
fingers.  The  grasp  was  also  feeble,  and  the  fingers  could 
not  be  doubled  into  the  hand  without  flexion  taking  place 
simultaneously  at  the  wrist.  When  the  hand  was  strongly 
extended  by  the  examiner,  the  grasp  became  much  stronger. 
The  numbness  was  referred  rather  vaguely  to  the  back  of 
the  hand  and  the  fingers,  especially  the  index  and  middle 
fingers,  but  suitable  tests  (horsehair  for  contact,  warm  and 
cool  objects  for  temperature)  indicated  only  trifling  impair- 
ment of  cutaneous  sensibility.  Ordinary  rough  tests,  as 
touching  with  the  finger,  revealed  no  impairment.  The 
electrical  reactions  were  the  same  for  the  two  arms.  There 
was  no  pain  or  tenderness  over  the  nerve  trunks.  The  af- 
fected arm  was  slightly  cooler  than  its  fellow.  All  other 
movements  were  normal,  except  that  flexion  at  the  elbow  was 
somewhat  feeble. 

The  extensor  muscles  began  to  regain  strength  after  a  few 
days,  and  at  the  end  of  three  or  four  weeks  recovery  was 
complete.  The  treatment  consisted  in  alternating  douches 
of  hot  and  cold  water. 

II. 

Injury  of  Ulnar  Ne?ve  at  the  Wrist. 

A  young  man  of  eighteen  accidentally  thrust  his  hand 
through  a  pane  of  glass,  and  received  a  deep  cut  on  the 


8 

palmar  surface  of  the  wrist.  The  wound  was  sewed  up  by 
his  physician  after  he  had  ascertained,  as  he  thought,  that 
the  deep  structures  of  the  wrist  had  suffered  no  injury.  The 
patient,  however,  became  at  once  aware  of  a  feeling  of 
"numbness  "in  the  little  and  ring  fingers;  and  when  the 
bandages  were  removed  he  found  the  hand  weak  and  thin. 
When  seen  by  me,  four  weeks  later,  all  the  interosseous 
muscles  were  found  to  be  wasted,  but  the  first  interosseous 
much  less  than  the  rest.  There  was  a  deep  hollow  between 
the  thumb  and  forefinger.  The  three  outer  fingers  (espe- 
cially the  ring  and  little)  remained  permanently  flexed  to 
some  extent  in  the  phalangeal  joints,  and  could  not  be  vol- 
untarily straightened.  The  fingers  remained  almost  in  ap- 
position, and  could  not  be  separated  without  being  at  the 
same  time  flexed,  and  even  then  but  little.  All  other  move- 
ments, both  of  flexion  and  extension,  were  substantially 
normal.  In  spite  of  the  numbness  of  the  two  smaller  fingers 
the  sensibility  of  the  skin  was  found  to  be  good  in  most  re- 
spects, except  over  a  small  area  on  the  outer  border  of  the 
hand,  opposite  the  root  of  the  little  finger.  Except  over  this 
area  the  lightest  touch  of  the  finger  was  everywhere  felt, 
and  even  the  horsehair  test  gave  normal  results.  The 
sensibility  to  pricking  and  to  the  wire-brush  (faradic)  was 
slightly  blunted,  especially  at  the  point  mentioned.  Press- 
ure over  the  scar,  which  lay  on  the  palmar  side  of  wrist, 
somewhat  toward  the  ulnar  border,  sent  a  thrill  through  the 
two  smaller  fingers. 

The  examination  with  electricity  showed  absence  of  the 
faradic  reaction  of  the  interosseous  muscles ;  while,  on  the 
other  hand,  the  same  muscles  reacted  with  a  slow,  wave-like 
motion  to  local  applications  of  galvanism,  the  positive  pole 
having  somewhat  more  effect  than  the  negative.  (This  is 
called  the  reaction  of  degeneration,  and  will  hereafter  be 
designated  as  R.  D.).  It  is  noteworthy  that  the  slowness  of 
the  contraction  was  not  so  strongly  marked  as  in  many  other 
cases. 


Improvement  began,  as  regards  the  sensibility,  within  a 
month  or  two  after  the  injury.  The  power  of  motion  began 
to  improve  at  a  somewhat  later  period,  but  by  the  end  of  a 
year  the  patient  had  substantially  recovered. 

III. 

Complete  Paralysis  of  Whole  Arm^  of  Sudden  Onset. 

A  middle-aged  man,  of  good  habits,  woke  in  the  morning 
with  his  right  arm  entirely  helpless,  even  including  all  move- 
ments at  the  shoulder.  He  gave  the  history  that  the  day  be- 
fore he  had  worked  for  many  hours  at  a  job  which  had  in- 
volved the  putting  in  of  a  large  number  of  screws,  and  that 
in  this  way  his  arm  had  become  greatly  fatigued.  There  was 
no  paralysis  of  the  leg  or  any  other  part  of  the  body,  and  no 
pain  or  other  sensory  disturbance  in  the  affected  arm.  The 
patient  was  seen  by  me  only  once,  but  I  learned  later  that 
a  few  days  after  his  visit  he  died  suddenly  with  symptoms 
that  were  thought  to  indicate  cerebral  disease. 

IV. 

Paralysis  of  Flexors  and  Extensors  of  Fingers.,  without 
Atrophy.     Recovery. 

A  woman  of  good  habits,  thirty  years  of  age,  found  her 
right  hand  growing  helpless,  without  apparent  cause.  The 
power  of  extension  of  the  fingers  was  lost  first,  though  not 
with  absolute  suddenness.  Then  the  flexion  became  in- 
volved, although  when  I  saw  her,  which  was  four  weeks  later, 
she  could  still  flex  her  fingers  slightly.  There  was  no  pain  or 
numbness.  The  condition  of  the  circulation  varied,  but  the 
hand  was  generally  cold.  The  patient  said  that  she  had 
continued  to  grow  worse  for  about  a  week,  since  when  her 
condition  had  remained  unchanged.  There  was  no  involve- 
ment of  the  face  or  leg  or  of  the  opposite  arm.  Careful  and 
repeated  examinations  with  electricity  showed  no  difference 


lO 

in  reaction  between  the  muscles  of  the  affected  and  those  of 
the  unaffected  hand,  nor  could  any  impairment  of  sensibility 
be  detected. 

The  patient  returned  two  weeks  later  with  the  report  that 
her  hand  was  practically  well.  She  said  that  the  motion  be- 
gan to  improve  the  very  next  day  after  her  visit  to  me,  and 
that  recovery  was  substantially  complete  at  the  end  of  a 
week.  On  examination,  the  power  of  motion  was  confirmed, 
though  it  was  found  to  be  very  jerky  in  character.  Indeed, 
this  tendency  to  jerky  movement  showed  itself  a  good  deal 
of  the  time  except  when  the  hand  was  absolutely  at  rest. 

V. 

"  Wrist- drop:' 

This  case  was  in  all  respects  essentially  like  Case  I.,  ex- 
cept as  regards  the  course.  The  patient  continued  without 
improvement  for  many  weeks,  in  spite  of  persistent  treatment 
by  electricity  and  otherwise,  the  electrical  reactions,  how- 
ever, remaining  unchanged.  At  the  end  of  perhaps  two 
months  the  treatment  was  interrupted  by  the  occurrence  of 
the  great  fire  of  1872,  which  obliged  the  patient,  who  be- 
longed to  the  fire  department,  to  work  day  and  night  for 
two  or  three  days.  Under  the  stimulus  of  this  excessive  ex- 
ertion he  began  to  improve,  and  was  soon  well. 

VI. 

«'  Wrist-drop:' 

This  was  also,  apparently,  a  case  of  pressure-paralysis 
coining  on  during  sleep,  but  involving,  (what  is  quite  un- 
usual) almost  all  the  muscles  of  the  arm,  and  especially  the 
deltoid.  The  electrical  examination  showed  a  moderate  de- 
gree of  R.  D.  of  the  deltoid  muscle,  but  otherwise  normal 
reactions  everywhere.  The  case  is  reported  for  a  single 
tact.     It  was    found,   namely,  that,  whereas  the   patient  (a 


H^'^^ijCyuf 


II 

young  man  of  somewhat  nervous  constitution)  was  wholly  un- 
able  to  flex  the  arm  at  the  elbow  or  to  contract  the  biceps  at 
all  (in  spite  of  the  fact  that  the  electrical  reactions  were  nor- 
mal), his  power  to  make  this  motion  returned  rapidly  and,  in- 
deed, almost  at  once  after  a  treatment  by  strong  faradiza- 
tion and  suitable  encouragement. 

VII. 
Injury  of  Brachial  Plexus  from  Forcible  Abduction  of  the  Arm. 

A  young  man  of  good  previous  health,  nineteen  years  old, 
was  ramming  a  blank  cartridge  into  a  cannon,  on  July  4, 
1873,  when  the  powder  exploded  and  his  arm  was  thrown 
with  great  force  into  extreme  extension,  besides  being  burned 
in  various  places.  He  was  examined  at  the  hospital  five  and 
a  half  months  later,  and  then  stated  that  for  the  first  few 
weeks  the  arm  had  been  wholly  paralyzed  as  regards  both 
sensation  and  motion.  At  the  time  of  the  examination  all 
the  muscles  of  the  forearm  were  found  wasted,  so  that 
scarcely  a  trace  remained.  The  biceps,  triceps,  deltoid,  and 
other  muscles  of  the  upper  arm  and  shoulder  were  better 
preserved.  The  fingers  were  blue  and  swollen.  They  lay 
habitually  in  a  position  of  semi-flexion,  but  could  be  extended 
and  flexed  voluntarily  to  a  very  slight  degree,  the  two 
smaller  fingers  better  than  the  two  larger.  The  thumb 
could  not  be  moved  at  all.  The  carpus  could  be  flexed  and 
extended  to  a  slight  degree.  Slight  flexion  and  extension  at 
the  elbow  were  possible  under  favorable  conditions,  and 
the  arm  could  be  abducted  from  the  body  to  about  25  de- 
grees. The  forearm  was  rotated  inward  so  that  the  knuckles 
pointed  forward  when  the  arm  hung  at  the  side  (pronated, 
ape-like,  position  of  the  arm).  The  arm  and  hand  were  re- 
ported as  habitually  cold,  yet  the  nails  were  said  to  grow 
better  on  the  paralyzed  hand  than  on  the  other. 

Neither  the  prick  of  a  pin  nor  water  heated  to  110°  F., 
nor  the  faradic  wire  brush  with  strong  currents,  excited  their 


12 

characteristic  sensations,  when  applied  within  an  area  which 
included  the  palmar  and  dorsal  surfaces  of  the  first  two 
fingers  and  the  thumb,  the  adjoining  part  of  the  hand,  and 
the  radial  border  of  the  forearm.  These  applications  did, 
however,  sometimes  excite  certain  vague  sensations,  of 
"thrilling  character,"  which  were  often  referred  to  parts  of 
the  hand  still  possessing  sensibility.  Over  the  rest  of  the 
hand  and  forearm  the  sensibility  was  better  preserved, 
though  impaired  in  all  respects,  but  even  the  sensibility  of 
the  upper  arm  was  defective  in  most  places.  The  electrical 
examination  showed  the  presence  of  R.  D.  throughout  the 
paralyzed  muscles.  The  patient  remained  under  treatment 
for  more  than  a  year,  in  the  course  of  which  time  the  follow- 
ing changes  occurred :  The  muscles  supplied  by  the  ulnar 
nerve,  together  with  the  deltoid,  triceps,  and  shoulder-blade 
group,  regained  much  strength,  and  at  the  same  time  the 
color  of  the  two  smaller  fingers  (ulnar  area  of  skin)  became 
nearly  normal,  while  the  others  (median  and  radial  areas) 
remained  blue,  the  same  blue  color  being  present  over  the 
radial  surface  of  the  forearm.  The  muscles  supplied  by  the 
median  nerve  remained  paralyzed  for  a  year  and  a  half, 
since  when  there  has  been  slight  gain.  The  extensor 
muscles  of  the  fingers  have  never  regained  their  power, 
even  up  to  the  present  date  (1900). 

When  the  skin  over  the  blue  area  was  scratched,  or 
touched  with  the  wire  brush  connected  with  the  faradic 
apparatus,  fine  red  lines  or  spots  would  appear,  and  the 
redness  thus  excited  would  remain  for  several  hours. 


VIII. 

An  unmarried  lady,  twenty  years  old,  and  of  good  previous 
health,  was  exposed  to  a  draft  from  an  open  window  while 
riding  in  the  train,  in  April.  The  next  morning  she  found 
herself  with  a  complete  facial  paralysis  of  the  left  side,  both 
upper  and  lower  areas  being  involved.    There  was  no  disease 


13 

of  the  ear.  Physical  examination  showed  that  when  the  face 
was  at  rest  scarcely  any  difference  was  noticeable  between 
the  two  sides,  though  on  attempts  at  motion  the  palsy  was 
plainly  evident.  For  the  first  few  days  some  pain  was  com- 
plained of  in  the  neighborhood  of  the  left  ear,  and  after  the 
first  few  days  the  tears  began  to  run  over  the  cheek,  excited 
by  cool  air  or  by  motions  of  the  face.  An  electrical  examina- 
tion made  some  weeks  later  showed  that  no  contractions  of 
the  affected  muscles  could  be  excited  by  stimulation  of  the 
nerve^  except  to  a  slight  degree  in  the  levator  anguli  oris, 
but  that  the  muscles  showed  an  excessive  local  irritability  to 
galvanism.  (These  signs  may  be  summarized  as  "  partial 
R.  D.")  Three  months  after  the  onset  voluntary  motion 
had  returned  to  a  considerable  extent,  having  first  shown 
itself  in  the  motions  at  the  angle  of  the  mouth ;  but  she  was 
troubled  with  involuntary  twitching  of  the  orbic.  oculi.  The 
electrical  reactions  were  more  nearly  normal  than  at  first, 
but  by  no  means  perfectly  so.  Five  months  from  the  onset 
the  only  sign  of  disease  was  a  deficient  play  of  the  muscles 
on  the  left  side,  and  some  signs  of  secondary  contracture. 
The  reactions  obtained  by  stimulation  of  the  nerve  with 
faradic  electricity  were  still  deficient,  but  the  R.  D.  had 
disappeared. 

IX. 

Facial  Palsy. 

Typical  case  of  facial  palsy  of  the  peripheral  type,  in  a 
lady  of  seventy.  No  disease  of  ear.  Marked  disturbance 
of  taste,  and  an  excessive  dryness  of  the  mouth;  great 
deformity  due  to  sagging  of  the  lower  eyelid  and  buccal 
muscles ;  typical  R.  D. ;  no  considerable  improvement  at  the 
end  of  a  year,  in  spite  of  persistent  treatment. 


14 

X. 

Facial  Palsy. 

Facial  palsy  in  a  child  of  three,  said  to  have  been  present 
since  birth.  No  electrical  reactions  of  any  sort  obtainable 
by  any  currents  that  the  child  could  bear. 

XI. 

Facial  Palsy, 

Man  thirty-nine  years  old.  Incomplete  facial  palsy  of  left 
side,  of  peripheral  t}'^pe,  all  movements  being  somewhat 
affected,  but  none  wholly  lost.  An  examination  at  the  end 
of  a  week  showed  a  preservation  of  the  f aradic  reactions ; 
no  R.  D. ;  no  impairment  of  taste.  On  inquiry,  it  appeared 
that  this  patient  had  had  disease  of  both  middle  ears  since 
infancy,  with  frequent  discharge ;  also,  that  about  two 
months  before  the  onset  of  the  palsy  he  had  had  consider- 
able pain  in  the  left  ear,  without  discharge ;  and,  a  month 
later,  persistent  headache  at  the  vertex,  sufficient  to  oblige 
him  to  give  up  work. 

XII. 

Facial  Palsy. 

Male  patient,  thirty-five  years  old  and  of  excellent  health. 
No  disease  of  ear.  Facial  palsy  of  very  gradual  onset,  first 
noticed  as  slight  stiffness  of  the  muscles,  then  by  the  falling 
in  of  the  cheek  between  the  teeth,  and  by  snapping  sensa- 
tions about  the  angle  of  the  jaw  on  opening  the  mouth 
widely.  At  the  time  of  the  examination  faradic  irritability 
of  the  nerve  was  absent,  and  typical  R.  D.  was  present.  A 
little  later  than  this  it  was  found  that  a  small  tumor  was 
present  behind  the  angle  of  the  jaw,  apparently  having  its 
basis  in  a  lymphatic  gland ;  and  still  later  this  increased 
somewhat  in  size,  the  paralysis  remaining  the  same.  It  is 
noteworthy  that  in  this  case  the  sensitiveness  of  the  affected 


Case  XIV. 


15 

side  of  the  face,  especially  the  forehead,  so  often  present  in 
acute  facial  palsy,  was  not  observed. 

XIII. 

Facial  Palsy, 

Male  patient,  eighteen  years  old.  Incomplete  facial  palsy, 
of  the  peripheral  type,  the  buccal  areas  being  involved  more 
than  the  orbital.  SHght  quantitative  impairment  of  the 
electrical  reaction.  The  interesting  point  in  relation  to  this 
case  is  that  the  patient  had  had  four  attacks  before  this  one, 
all  of  the  peripheral  type  and  relatively  transient  in  duration. 
The  previous  attacks  had  involved  the  opposite  side  to  this 
one.  No  other  member  of  the  patient's  family  had  suffered 
in  this  way ;  but  another  case  may  be  mentioned  where 
three  seizures  occurred  in  two  members  of  the  same  family, 
the  family  history  being  also  marked  by  a  tendency  to 
severe  constitutional  disorders  of  nutrition  of  different  sorts. 

XIV. 

Severe  Pain,  with   Herpetic  Eruption,  over  the  Left  Frontal 

Area. 

A  gentleman  of  fifty-five,  previously  strong  and  well,  was 
attacked  with  pain  in  the  left  frontal  area,  the  left  eye,  and 
the  left  side  of  the  nose  near  the  root.  This  pain  was  severe 
and  nearly  constant,  but  every  hour  or  so  there  would  be  an 
exacerbation  of  a  few  moments'  duration,  during  which  the 
suffering  was  so  extreme  that  his  nurse  was  kept  on  the  close 
watch,  with  orders  to  clap  on  at  once  a  bag  of  hot  hops. 
After  a  week  or  less  a  vesicular  eruption  appeared,  scattered 
over  the  affected  area.  The  skin  over  the  whole  area  was 
reddened  and  inflamed,  though  irregularly.  The  pain  was 
somewhat  relieved  by  persistent  use  of  warm  applications  of 
constant  temperature,  changed  to  hot  applications  during  the 
exacerbations.     Collodion  painted  on  also  gave  some  relief, 


i6 

and  likewise  internal  medication  by  aconitia,  quinine  in  large 
doses,  and  anodynes  of  various  sorts.  After  some  weeks 
the  pain  subsided  to  some  extent,  but  a  modified  and  some- 
what severe  neuralgia  persisted  for  many  years.  The  vesicu- 
lar eruption  gave  place  to  an  atrophied  condition  of  the  skin, 
with  loss  of  pigment,  and  pitting  corresponding  to  the 
vesicles. 

XV. 
Ptosis,  due  to  Spasm  of  the  Orbicularis  Oculi. 

A  girl  of  twelve  years  of  age  awakened  one  morning  to 
find  herself  unable  to  speak  aloud.  This  symptom  persisted 
for  a  week,  at  the  end  of  which  time  she  was  able  to  talk 
naturally  for  a  few  hours  at  a  time,  after  which  the  trouble 
would  suddenly  return.  She  gradually  recovered  in  the 
course  of  three  or  four  weeks.  One  month  later,  while 
dressing,  both  her  eyes  became  so  tightly  closed  that  she 
could  not  open  them,  even  with  the  aid  of  her  fingers.  After 
two  or  three  days  the  right  eye  opened  naturally,  but  the  left 
remained  obstinately  closed.  This  condition  had  persisted 
two  weeks  when  she  applied  for  treatment. 

Physical  examination  showed  a  marked  spasm  of  the  left 
orbicularis  oculi,  and  any  attempt  made  by  the  patient  to 
open  the  eye  only  increased  the  spasm,  and  brought  on  a 
contraction  of  the  muscles  of  the  lower  part  of  the  face. 
(See  photograph.) 

There  were  no  other  motor  disturbances  and  no  sensory 
disorders.  Daily  treatment  resulted  in  temporary  power  to 
open  the  eye,  and  at  the  end  of  a  week  the  trouble  had  dis- 
appeared. It  was  learned  that  the  patient's  mother  was  at 
one  time  troubled  with  numbness  of  the  hands  for  several 
months ;  and  sometimes,  with  no  apparent  cause,  the  first 
two  fingers  of  her  right  hand  would  turn  perfectly  white  and 
feel  cold  and  "  dead.'* 


Case  XV. 


Case  XV. 


Case  similar  to  XV. 


Case  similar  to  XV. 


XVI. 

Facial  Palsy  ^  preceded  by  Convulsions  of  Face  and  Arms. 

A  woman  sixty-five  years  old  awoke  one  morning  to  find 
the  lower  muscles  of  her  face  paralyzed  on  the  left  side. 
During  the  previous  day  she  had  had  two  spells,  lasting  four 
or  five  minutes  each,  during  which  the  left  facial  muscles 
and  the  left  arm  had  twitched  convulsively.  Similar  attacks 
recurred  several  times  in  the  course  of  the  next  two  days, 
and  it  was  on  account  of  these  that  she  applied  for  treat- 
ment. 

Examination  showed  the  pupils  to  be  equal  and  to  exhibit 
normal  reactions.  The  eyes  could  be  moved  normally  in  all 
directions.  Both  the  eyehds  could  be  closed  synchronously. 
She  could  wink  naturally  with  the  right  eye  alone,  but 
the  left  eye  could  not  be  closed  independently  of  the  right. 
The  frontalis  muscle  contracted  normally,  but  there  was 
complete  paralysis  of  the  lower  facial  muscles,  and  the  mouth 
was  drawn  markedly  to  the  right.  R.  D.  was  absent. 
There  was  no  impairment  in  the  strength  of  the  arm-muscles, 
and  no  disturbance  of  sensibility.  The  left  wrist-jerk  was 
iiveher  than  the  right,  while  the  patellar  reflexes  were 
normal. 

The  heart-sounds  were  of  good  quality,  except  that  the 
aortic  second  sound  was  sharp  and  valvular.  No  murmurs 
were  heard,  and  there  was  no  enlargement.  The  temporal 
and  radial  arteries  were  palpable  but  not  calcified.  The 
pulse  was  regular  and  of  rather  high  tension.  Urine-ex- 
amination showed  nothing  abnormal. 

XVII. 

Facial  Palsy  ;  Herpes  of  Face  and  Neck. 

On  June  13,  1902,  a  lady  of  forty  was  attacked  with  pain 
within  and  immediately  below  and  behind  the  left  ear. 
From  this  area  as  a  centre,  the  pain  streamed  up  more  or 


i8 


less  into  the  left  eye  and  to  the  top  of  the  head,  and  also 
down  into  the  neck,  where  there  was  a  sensation  as  of  hot 

coals.  Two  days  later  a  typi- 
cal herpetic  eruption  appeared 
over  various  parts  of  the  whole 
painful  area,  though  less  in 
and  about  the  ear  than  on  the 
neck  between  the  jaw  and 
clavicle.  Scattered  vesicles 
broke  out  on  the  side  of  the 
face,  and  there  were  a  few 
down  over  the  shoulder,  even 
to  below  the  spine  of  the  scap- 
ula. 

These  vesicles  continued  to 
come  in  successive  crops  for 
a  week  or  more.  They  fre- 
quently coalesced,  and  eventu- 
ally dried  up.  The  pain  grew 
Case  XVII  worse  for  a  week,  then  began 

to  lessen. 
At  this  period  the  patient  became  aware  that  she  could 
not  use  her  upper  lip,  and  then  that  she  could  not  close  her 
eye  and  that  her  tongue  felt  queer,  and  within  a  day  the 
whole  left  side  of  the  face  was  paralyzed,  and  she  was  un- 
able to  recognize  sugar,  salt,  or  vinegar  placed  on  the  left 
half  of  the  tongue. 

An  electrical  examination,  made  June  25,  three  days  after 
the  onset  of  the  paralysis,  indicated  a  slight  quantitative 
impairment  of  the  nerve-muscle  reactions,  but  gave  no  evi- 
dence of  the  reaction  of  degeneration. 


19 

XVIII. 

Supra-orbital  Neuralgia  of  Migrainoid  Type. 

A  middle-aged  woman  —  of  good  health  except  that  in  her 
earlier  years  she  had  suffered  from  periodical  attacks  of 
migraine,  which  had  also  appeared  in  several  members  of 
her  family  —  began  to  show  a  tendency  to  periodical  attacks 
of  severe  throbbing  pains  in  the  supra-orbital  region  and  eye 
of  the  left  side,  coming  on  frequently  after  an  attack  of 
coryza,  but  also  at  times  without  that  cause.  Each  attack 
lasted  one  or  two  weeks,  the  pain  recurring  every  morning 
at  eight  or  nine  o'clock,  increasing  in  severity  until  one 
o'clock,  then  gradually  subsiding,  and  disappearing  about 
three  o'clock.  Nausea  and  vomiting  accompanied  the 
severer  attacks.  Occasionally  there  would  be  a  recurrence 
of  the  pain  in  the  evening.  Quinine  in  large  doses,  taken 
four  hours  before  the  beginning  of  a  seizure,  would  some- 
times avert  it ;  but  this  soon  lost  its  effect  to  some  extent. 
Treatment  of  the  nose,  of  such  a  kind  as  to  secure  freer 
drainage  in  the  ethmoid  and  frontal  sinuses,  was  of  some 
benefit.  In  the  intervals  between  the  attacks  she  was  per 
fectly  well. 

XIX. 

Severe  Frontal  Pain  of  Chronic  Course^  relieved  by  Operation. 

An  elderly  lady  had  suffered  for  years  from  an  intense 
"  epileptiform  "  pain  in  the  supra-orbital  area,  with  little  re- 
lief except  sometimes  at  night.  The  pain  recurred  spontane- 
ously and  was  also  excited  by  touching  or  brushing  the  skin. 
Occasional  free  intermissions  of  several  weeks'  duration  had 
occurred.  There  was  also  some  pain  of  a  similar  character 
in  the  infra-orbital  area.  Finally,  excision  of  the  supra- 
and  infra-orbital  nerves  brought  complete  relief,  and  this 
lasted  until  the  patient's  death,  some  years  later.  Marked 
alterations  were  found  in  the  nerve. 


20 


XX. 


Pain  in  the  Distribution  of  the  Ophthalmic  Division  of  the  Fifth 
Nerve,  recurring  Daily  at  the  Same  Hour. 

The  patient  was  a  healthy  but  somewhat  neurasthenic  man, 
fifty  years  old.  Ever  since  boyhood  he  had  had  attacks 
of  the  above-mentioned  type,  recurring  at  intervals  of  several 
years,  each  attack  lasting  from  three  to  six  days.  Coryza, 
with  inflammation  in  the  frontal  sinus,  had  been  the  exciting 
cause  in  almost  every  instance.  The  severity  of  the  attacks 
had  varied  greatly,  and  in  the  severest  examples  there  had 
been,  besides  the  morning  recurrence,  a  return  of  deep- 
seated,  dull  headache  toward  nightfall.  One  group  of  at- 
tacks was  prolonged  for  months,  and  seemed  to  give  rise  to  a 
sort  of  indolent  neuritis  of  the  ophthalmic  division  of  the  fifth 
nerve,  which  led,  in  its  turn,  to  a  thickening  of  the  perios- 
teum under  and  above  the  eyebrow,  and  this  had  not  wholly 
disappeared  at  the  end  of  several  years.  Prolonged  reading 
would  cause  aching  of  the  eye  on  the  affected  side,  even  in 
the  intervals  between  attacks,  and  at  times  scanty  crops  of 
tender  papules  would  appear  on  the  skin  of  the  forehead, 
independently  of  the  neuralgia  or  during  prolonged  seizures. 
Fatigue  might  also  bring  on  slight  pain  at  any  time. 

The  family  and  personal  history  in  this  case  are  quite  in- 
teresting. Several  of  the  patient's  immediate  family  had 
suffered,  though  but  slightly,  from  typical  migraine ;  his  ma- 
ternal grandfather,  his  mother,  his  brothers  and  sisters,  and 
his  daughter  had  been  subject  to  attacks  of  the  same  sort 
as  his  own,  and  a  cousin  had  had  typical  migraine  all  her 
life.  The  patient  had  had  once,  but  only  once,  in  his  life, 
an  attack  of  vibrating  scotoma,  lasting  half  an  hour  and 
not  followed  by  headache.  A  brother  had  had  a  similar 
single  attack  of  scotoma,  followed  by  headache, —  in  short, 
an  attack  of  migraine. 

The  mother  had  had  numerous  attacks  of  intermittent  mi- 
grainoid  neuralgia,  just  like  those  of  the  patient ;  and  a  sis- 


17 

XVI. 

Facial  Palsy,  preceded  by  Convulsions  of  Face  and  Arms. 

A  woman  sixty-five  years  old  awoke  one  morning  to  find 
the  lower  muscles  of  her  face  paralyzed  on  the  left  side. 
During  the  previous  day  she  had  had  two  spells,  lasting  four 
or  five  minutes  each,  during  which  the  left  facial  muscles 
and  the  left  arm  had  twitched  convulsively.  Similar  attacks 
recurred  several  times  in  the  course  of  the  next  two  days, 
and  it  was  on  account  of  these  that  she  applied  for  treat- 
ment. 

Examination  showed  the  pupils  to  be  equal  and  to  exhibit 
normal  reactions.  The  eyes  could  be  moved  normally  in  all 
directions.  Both  the  eyelids  could  be  closed  synchronously. 
She  could  wink  naturally  with  the  right  eye  alone,  but 
the  left  eye  could  not  be  closed  independently  of  the  right. 
The  frontalis  muscle  contracted  normally,  but  there  was 
complete  paralysis  of  the  lower  facial  muscles,  and  the  mouth 
was  drawn  markedly  to  the  right.  R.  D.  was  absent. 
There  was  no  impairment  in  the  strength  of  the  arm-muscles, 
and  no  disturbance  of  sensibility.  The  left  wrist-jerk  was 
livelier  than  the  right,  while  the  patellar  reflexes  were 
normal. 

The  heart-sounds  were  of  good  quality,  except  that  the 
aortic  second  sound  was  sharp  and  valvular.  No  murmurs 
were  heard,  and  there  was  no  enlargement.  The  temporal 
and  radial  arteries  were  palpable  but  not  calcified.  The 
pulse  was  regular  and  of  rather  high  tension.  Urine-ex- 
amination showed  nothing  abnormal. 

XVII. 

Facial  Palsy ;  Herpes  of  Face  and  Neck. 

On  June  13,  1902,  a  lady  of  forty  was  attacked  with  pain 
within  and  immediately  below  and  behind  the  left  ear. 
From  this  area  as  a  centre,  the  pain  streamed  up  more  or 


i8 


less  into  the  left  eye  and  to  the  top  of  the  head,  and  also 
down  into  the  neck,  where  there  was  a  sensation  as  of  hot 

coals.  Two  days  later  a  typi- 
cal herpetic  eruption  appeared 
over  various  parts  of  the  whole 
painful  area,  though  less  in 
and  about  the  ear  than  on  the 
neck  between  the  jaw  and 
clavicle.  Scattered  vesicles 
broke  out  on  the  side  of  the 
face,  and  there  were  a  few 
down  over  the  shoulder,  even 
to  below  the  spine  of  the  scap- 
ula. 

These  vesicles  continued  to 
come  in  successive  crops  for 
a  week  or  more.  They  fre- 
quently coalesced,  and  eventu- 
ally dried  up.  The  pain  grew 
worse  for  a  week,  then  began 
to  lessen. 
At  this  period  the  patient  became  aware  that  she  could 
not  use  her  upper  lip,  and  then  that  she  could  not  close  her 
eye  and  that  her  tongue  felt  queer,  and  within  a  day  the 
whole  left  side  of  the  face  was  paralyzed,  and  she  was  un- 
able to  recognize  sugar,  salt,  or  vinegar  placed  on  the  left 
half  of  the  tongue. 

An  electrical  examination,  made  June  25,  three  days  after 
the  onset  of  the  paralysis,  indicated  a  slight  quantitative 
impairment  of  the  nerve-muscle  reactions,  but  gave  no  evi- 
dence of  the  reaction  of  degeneration. 


Case  XVII. 


19 

XVIII 

Supra-orbital  Neuralgia  of  Migrainoid  Type. 

A  middle-aged  woman  —  of  good  health  except  that  in  her 
earlier  years  she  had  suffered  from  periodical  attacks  of 
migraine,  which  had  also  appeared  in  several  members  of 
her  family  —  began  to  show  a  tendency  to  periodical  attacks 
of  severe  throbbing  pains  in  the  supra-orbital  region  and  eye 
of  the  left  side,  coming  on  frequently  after  an  attack  of 
coryza,  but  also  at  times  without  that  cause.  Each  attack 
lasted  one  or  two  weeks,  the  pain  recurring  every  morning 
at  eight  or  nine  o'clock,  increasing  in  severity  until  one 
o'clock,  then  gradually  subsiding,  and  disappearing  about 
three  o'clock.  Nausea  and  vomiting  accompanied  the 
severer  attacks.  Occasionally  there  would  be  a  recurrence 
of  the  pain  in  the  evening.  Quinine  in  large  doses,  taken 
four  hours  before  the  beginning  of  a  seizure,  would  some- 
times avert  it ;  but  this  soon  lost  its  effect  to  some  extent. 
Treatment  of  the  nose,  of  such  a  kind  as  to  secure  freer 
drainage  in  the  ethmoid  and  frontal  sinuses,  was  of  some 
benefit.  In  the  intervals  between  the  attacks  she  was  per- 
fectly well. 

XIX. 

Severe  Frontal  Pain  of  Chronic  Course^  relieved  by  Operation, 

An  elderly  lady  had  suffered  for  years  from  an  intense 
"  epileptiform  "  pain  in  the  supra-orbital  area,  with  little  re- 
lief except  sometimes  at  night.  The  pain  recurred  spontane- 
ously and  was  also  excited  by  touching  or  brushing  the  skin. 
Occasional  free  intermissions  of  several  weeks'  duration  had 
occurred.  There  was  also  some  pain  of  a  similar  character 
in  the  infra-orbital  area.  Finally,  excision  of  the  supra- 
and  infra-orbital  nerves  brought  complete  relief,  and  this 
lasted  until  the  patient's  death,  some  years  later.  Marked 
alterations  were  found  in  the  nerve. 


20 


XX. 


Pain  in  the  Distribution  of  the  Ophthalmic  Division  of  the  Fifth 
Nerve,  recurring  Daily  at  the  Sajne  Hour. 

The  patient  was  a  healthy  but  somewhat  neurasthenic  man, 
fifty  years  old.  Ever  since  boyhood  he  had  had  attacks 
of  the  above-mentioned  type,  recurring  at  intervals  of  several 
years,  each  attack  lasting  from  three  to  six  days.  Coryza, 
with  inflammation  in  the  frontal  sinus,  had  been  the  exciting 
cause  in  almost  every  instance.  The  severity  of  the  attacks 
had  varied  greatly,  and  in  the  severest  examples  there  had 
been,  besides  the  morning  recurrence,  a  return  of  deep- 
seated,  dull  headache  toward  nightfall.  One  group  of  at- 
tacks was  prolonged  for  months,  and  seemed  to  give  rise  to  a 
sort  of  indolent  neuritis  of  the  ophthalmic  division  of  the  fifth 
nerve,  which  led,  in  its  turn,  to  a  thickening  of  the  perios- 
teum under  and  above  the  eyebrow,  and  this  had  not  wholly 
disappeared  at  the  end  of  several  years.  Prolonged  reading 
would  cause  aching  of  the  eye  on  the  affected  side,  even  in 
the  intervals  between  attacks,  and  at  times  scanty  crops  of 
tender  papules  would  appear  on  the  skin  of  the  forehead, 
independently  of  the  neuralgia  or  during  prolonged  seizures. 
Fatigue  might  also  bring  on  slight  pain  at  any  time. 

The  family  and  personal  history  in  this  case  are  quite  in- 
teresting. Several  of  the  patient's  immediate  family  had 
suffered,  though  but  slightly,  from  typical  migraine ;  his  ma- 
ternal grandfather,  his  mother,  his  brothers  and  sisters,  and 
his  daughter  had  been  subject  to  attacks  of  the  same  sort 
as  his  own,  and  a  cousin  had  had  typical  migraine  all  her 
life.  The  patient  had  had  once,  but  only  once,  in  his  life, 
an  attack  of  vibrating  scotoma,  lasting  half  an  hour  and 
not  followed  by  headache.  A  brother  had  had  a  similar 
single  attack  of  scotoma,  followed  by  headache, —  in  short, 
an  attack  of  migraine. 

The  mother  had  had  numerous  attacks  of  intermittent  mi- 
grainoid  neuralgia,  just  like  those  of  the  patient ;  and  a  sis- 


21 

ter  had  had  a  single  group  of  severe  seizures  of  the  same 
sort,  covering  a  space  of  two  weeks.  These  had  followed  a 
period  of  intense  fatigue  and  excitement,  besides  a  pro- 
longed exposure  to  a  cold  wind  and  the  painful  extraction  of 
a  large  tooth.  The  sister's-  attack  had  been  succeeded  by 
a  severe  pseudo-angina  pectoris,  which  lasted  for  several 
weeks  and  made  walking  very  difficult.  The  same  sister, 
when  fifteen  years  old,  had  had  repeated  attacks  of  inter- 
mittent headache  of  the  same  sort  as  those  of  the  patient. 

xxr. 

Facial  Neuralgia. 

This  patient  is  a  man  of  sixty-five  years,  of  good  general 
health,  good  nutrition,  and  with  a  finely  shaped  head  and  large 
frame.  His  symptoms  have  been  present  for  three  years, 
and  the  onset  was  gradual  and  without  known  cause.  He 
first  noticed  a  kind  of  stinging  sensation  at  the  seat  of  the 
subsequent  pain,  and  this  troubled  him  through  the  winter 
but  disappeared  in  the  spring.  The  next  winter  this  re- 
turned, and  with  greater  intensity,  though  the  pain  w^as  not 
so  severe  even  then  as  it  was  at  the  time  of  the  first  ex- 
amination. The  principal  seat  of  the  pain  has  been,  from 
the  first,  the  floor  of  the  right  nostril,  where  "  jumping  " 
and  "  stinging "  sensations  of  great  severity  could  be 
brought  on  by  touching  the  spot  itself,  or  by  any  motion 
of  the  lips.  Occasionally  he  has  a  darting  sensation  at  a 
point  on  the  right  side  of  the  head  near  the  vertex,  sug- 
gesting the  prick  of  a  needle ;  and,  when  this  point  is 
touched,  the  pain  will  start  up  in  the  nostril.  He  has 
had  four  teeth  drawn,  but  without  relief.  There  is  no 
pain  during  the  night  or  when  the  mouth  is  held  perfectly 
quiet.  Occasionally  the  pain  streams  up  into  the  eye,  and 
makes  it  water.  His  hearing  is  affected  in  a  peculiar  way : 
he  can  hear  his  clock  tick  even  when  a  long  distance  away, 
but,  when  a  number  of  people  are  talking  in  the  same  room, 
he  gets  confused,  and  has  constantly  to  ask  what  is  said. 


22 

Although  this  patient  was  not  troubled  especially  by  con- 
stipation he  was  directed  to  take  castor  oil  every  morning, 
in  the  dose  of  half  an  ounce  to  two  ounces.  Within  a  few 
days  after  this  treatment  was  begun  he  felt  better,  and 
eventually  recovered ;  he  has  remained  substantially  well 
ever  since,  though  an  interval  of  two  years  has  elapsed. 

XXII. 

Intercostal  Neuralgia. 

A  woman  of  fifty-five  came  complaining  of  severe  pain  in 
the  left  chest,  sometimes  rather  anteriorly,  in  the  cardiac 
region,  and  again  rather  in  the  axillary  area.  This  came  on 
from  fatigue  and  changes  of  weather,  especially  changes 
from  clear  to  stormy  weather  but  sometimes  also  the  re- 
verse. 

On  physical  examination  it  was  found  that  the  skin  cor- 
responding to  the  distribution  of  the  pain  was  covered  with 
brownish  or  whitish  depressed  scars,  and,  on  inquiry,  the 
patient  gave  an  account  of  having  had  an  attack  of  very  in- 
tense pain  in  this  same  locality  two  years  previously,  at 
which  time  the  skin  became  inflamed.  Ever  since  that  time 
she  had  continued  to  have  more  or  less  pain,  as  first  de- 
scribed. The  patient  was  of  neurotic  temperament,  and 
lived  under  rather  poor  conditions.  Tonics  and  local  appli- 
cations brought  her  a  good  deal  of  relief. 

XXIII. 

Intercostal  Neuralgia. 

A  gentleman  of  forty  was  attacked  suddenly  with  a  pain 
over  a  small  area  in  the  left  side,  at  about  the  level  of  the 
fourth  rib,  of  such  severity  that  he  turned  pale  and  vomited, 
and  had  to  be  given  a  subcutaneous  injection  of  morphine. 
After  this  began  to  act,  the  pain  ceased.  The  feeling, 
while  it  lasted,  was  as  if  some  blunt  instrument  was  being 
pressed  with  great  force  against  the  ribs  at  a  certain  point. 


23 

The  apparent  cause  of  this  attack  was  fatigue  from 
a  short  but  stormy  sea-voyage,  associated  with  a  pro- 
longed fast.  The  patient  had  suffered  in  the  past  from 
other  forms  of  neuralgia  and  other  neuroses,  and  the  same 
could  be  said  of  other  members  of  his  family. 


XXIV. 

Severe  Neuralgic  Pain  over  the  Back  of  the  Head 
on  the  Left  Side. 

The  patient  was  a  clergyman  and  teacher  of  somewhat 
advanced  age,  and  had  suffered  very  intensely  from  this 
pain  for  several  years,  with  some  periods  of  relief.  No  treat- 
ment had  been  of  benefit.  No  other  part  of  the  head  had 
been  involved,  but  examination  showed  a  hyperaesthetic  con- 
dition of  the  skin  to  contact  and  even  deeper  pressure  over 
the  whole  left  side  of  the  body.  Pulling  the  hairs  on  this 
side  of  the  body  caused  more  pain  than  on  the  other  side. 
Various  methods  of  treatment  were  tried,  but  nothing  gave 
him  permanent  relief. 

No  record  is  preserved  of  the  patient's  physical  condition 
in  other  respects,  but  it  may  be  said  that  he  exhibited  no 
cardiac  or  renal  disease  at  the  time  of  the  examination.  He 
died  some  years  later  from  an  intercurrent  disease. 


XXV. 

Almost  Constant  Pain  in  the  Back  of  the  Neck^  on  the  Left 
Side,  of  Long  Duration ;  also,  Pain  on  the  Right  Side 
of  the  Face. 

The  patient  is  a  married  lady  of  forty-three,  an  eminent 
writer,  without  children.  The  pain  in  the  back  of  the  neck 
has  been  present  for  about  a  year,  but  previously  to  that  she 
had  suffered  from  paroxyms  of  neuralgia  on  the  right  side 
of  the  face,  due  apparently  to  disease  in  the  antrum.     This 


24 

cavity  was  finally  opened  and  cleaned  out,  and  eventually 
dead  bone  was  found  and  removed.  Immediately  after  the 
operation  the  pain  in  the  back  of  the  neck  began  in  full 
force.  It  now  recurs  periodically,  as  often  as  three  or  four 
times  a  week,  beginning  at  three  or  four  o'clock  every 
morning,  and  lasting  until  the  patient  gets  up  and  about. 
Occasionally  it  comes  back  in  the  afternoon.  Besides  these 
two  kinds  of  pains  the  patient  has  had  severe  left-sided 
headaches,  preceded  by  aphasia,  with  numbness  of  the  right 
hand  and  vibrating  scotoma.  Sometimes  she  has  been  free 
from  the  pain  in  the  neck  for  two  or  three  weeks  at  a  time, 
but  it  is  noteworthy  that,  in  proportion  as  the  pain  in  the 
neck  has  been  more  constant,  the  tendency  to  the  left-sided 
headaches  has  been  less.  The  patient  also  suffers  con- 
stantly from  a  tendency  to  frequent  micturition,  so  that  she 
is  unable  to  go  more  than  half  an  hour  without  passing 
urine.  This  seemed  at  first  to  be  explained  by  the  presence 
of  multiple  fibroids,  but  there  must  have  been  some  other 
cause  as  well,  since  their  removal  did  not  bring  about  a  cure. 
Physical  examination  shows  a  well-nourished,  healthy-look- 
ing, but  rather  high-strung,  excitable  person.  Nothing  is 
found  locally  in  the  neck  except  a  slight  tenderness  on  deep 
pressure.  All  the  organs,  both  thoracic  and  abdominal,  are 
normal,  except  as  stated.  No  treatment  hitherto  suggested 
has  been  of  service. 

XXVI. 

Intejise  Pain  in  the  Left  Side. 

This  patient  was  a  man  of  thirty-two,  strongly  built,  of 
easy  circumstances,  and  presenting,  when  first  examined, 
an  appearance  of  good  nutrition.  His  story  was  that  he 
had  begun  to  have  a  slight  pain  in  his  left  side,  from  the 
cardiac  region  to  near  the  shoulder-blade,  about  three  years 
previously,  and  that  this  had  been  growing  steadily  worse 
ever  since.  It  followed  him,  he  said,  night  and  day,  and 
was  increased  by  movement  and  relieved  by  rest.     He  could 


25 

not,  however,  lie  down,  because  this  position  made  the  pain 
especially  intense,  and  he  was  forced,  therefore,  to  sleep  in 
a  sitting  position,  with  the  head  thrown  forward  and  resting 
on  the  back  of  a  chair.  When  he  leaned  back  the  severe 
pain  soon  began,  little  by  little,  to  return,  usually  preceded 
by  a  sort  of  pulling  sensation  of  gradually  increasing  inten- 
sity. He  was  unable  to  get  on  without  morphine,  but 
avoided  it  so  far  as  possible. 

Physical  examination  showed  a  moderate  enlargement  of 
the  heart  with  a  thumping  apex  beat,  also  a  to  and  fro 
murmur  over  the  aortic  orifice.  A  diastolic  murmur  was 
heard  also  at  the  apex,  probably  by  transmission.  He  had 
had  gonorrhoea,  and  some  sort  of  sore  which  went  away  with 
treatment,  and  also  a  suppurating  bubo  ;  and  a  scar  was  found 
on  the  glans  near  the  corona.  When  the  pain  was  severe 
it  reached  to  the  middle  of  the  sternum,  and  at  such  times 
the  left  arm  was  also  somewhat  painful,  the  sensation  being 
as  of  something  shooting  down  through  the  arm  and  into  the 
fingers,  especially  the  two  smaller  fingers. 

This  patient  was  kept  under  observation  off  and  on  for 
several  years,  and  various  diagnoses  were  considered  before 
the  right  one  was  arrived  at.  Finally  this  was  arrived  at 
by  the  aid  of  another  sort  of  physical  examination  not  here 
recorded.  One  physician  after  another,  failing  to  discover 
any  cause  for  his  pain,  and  noting  the  fact  that  it  would 
sometimes  remit  as  mysteriously  as  it  came,  declared  their 
belief  that  he  was  hysterical  and  hypochondriacal,  or  suffer- 
ing from  "  habit-pain."  It  may  be  said  that  maximum  doses 
of  potassium  iodide  and  mercury  were  repeatedly  used  with- 
out effect. 

XXVII. 

Neuralgic  Pain  of  Burning  Character  in  Right  Hand 

and  Arm. 

A  female  patient,  thirty-eight  years  old,  came  for  treat- 
ment on  account  of  severe  pain  in  the  right  arm  and   hand, 


26 

which  had  been  present  for  a  number  of  months,  but  had 
grown  much  worse  of  late.  It  was  especially  severe  in 
certain  spots,  as  the  palm  of  the  hand  and  the  third  finger. 
In  these  places  the  pain  was  of  a  burning  character,  suggest- 
ing the  contact  of  hot  coals.  Inquiry  into  the  personal 
history  showed  that  this  patient  had  had  several  attacks  of 
this  sort,  the  first  as  long  as  sixteen  years  before,  and  also 
that  she  belonged  to  an  intellectual  but  neurotic  family,  and 
that  her  sister  had  had  an  acute  attack  like  that  from  which 
she  now  suffered.  The  present  attack  had  begun  in  cold 
weather ;  and  the  pain  had  involved  at  times  the  shoulder 
and  shoulder-blade,  as  well  as  the  arm.  It  was  worst  at 
about  three  o'clock  in  the  morning  and  from  then  until 
eight,  but  rarely  disappeared  entirely.  The  median  nerve 
could  be  felt  as  a  distinct  cord  throughout  its  humeral 
course.  Relief,  and  finally  cure,  was  brought  about  by 
repeated,  superficial  cauterization ;  but  the  pain  returned  in 
some  degree  a  year  later. 

XXVIII. 

Wide-spread  Atrophic  Paralysis,  of  Acute  Onset,  in  a   Young 
Child ;  associated  at  first  with  Fever. 

A  child  of  three,  of  ordinarily  good  health,  went  to  bed 
feeling  somewhat  sick,  though  without  serious  symptoms, 
but  waked  in  the  morning  unable  to  walk  or  use  the  legs, 
and  scarcely  able  to  move.  During  the  night  she  had  been 
somewhat  feverish,  but  the  fever  did  not  continue.  For  the 
first  week  she  was  unable  to  raise  the  hands  as  high  as  the 
head,  but  could  always  move  both  hands  and  arms  some- 
what. Some  pain  was  complained  of  in  the  left  arm,  and  a 
feeling  which  she  described  by  likening  it  to  "  needles  in  the 
bed."  There  was  also  a  feeling  of  soreness  about  the  neck, 
and  she  objected  greatly  to  being  moved.  For  the  first  two 
or  three  weeks  she  seemed  too  exhausted  to  talk,  and,  in 
fact,  could  hardly  be  understood,  so  that  it  is  possible  that 
there  was  partial  paralysis  of  the  vocal  muscles.     At  times 


^7 

there  was  slight  deUrium.  After  a  week  or  two  she  began 
to  improve  and  became  able  to  turn  in  bed,  but  she  could 
liot  for  a  long  time  sit  up  alone.  She  was  so  sick  that  for 
some  weeks  no  close  examination  was  made,  but  she  was 
then  found  to  be  completely  paralyzed  below  the  waist. 
Disorders  of  sensibility  were,  however,  not  present,  except 
that  there  was  pain  on  handling.  The  muscles  were  flaccid, 
soft,  and  small.  Well-marked  R.  D.  was  found,  on  electrical 
examination,  in  the  tibialis  anticus  and  gastrocnemius.  No 
response  could  be  obtained  from  the  thigh  muscles  with  the 
faradic  current ;  and  it  is  probable  that  R.  D.  would  have 
been  found  here  also,  but  that  the  examination  was  desisted 
from  on  account  of  pain. 

XXIX. 

Wide-spread  Muscular  Paralysis  and  Atrophy^  of  Acute  Onsets 
associated  at  first  with  Severe  Pain. 

This  patient  was  a  young  woman,  unmarried,  and  of  good 
previous  health.  Her  illness  occurred  in  the  latter  part  of 
August,  1880,  after  a  period  of  exceedingly  hot  weather. 
As  a  possible  exciting  cause,  she  had  had  an  exposure  to  the 
wet  while  menstruating,  as  a  result  of  which  the  menstruation 
had  ceased.  The  symptoms  began  with  severe  generalized 
pain  and  retention  of  the  urine.  It  is  not  known  whether 
fever  was  present  at  first,  but  presumably  this  was  the  case, 
since  as  long  as  three  weeks  later,  at  which  time  she  first 
entered  the  hospital,  the  temperature  was  99.8°  F.  The 
initial  symptoms  were  quickly  followed  by  a  rapidly  increas- 
ing and  wide-spread  muscular  paralysis,  associated  with 
paraesthesia  of  the  extremities.  Nearly  all  the  superficial 
muscles  of  the  body  became  very  weak  and  more  or  less 
wasted,  but  the  muscles  of  the  right  arm,  especially  those 
involved  in  abduction  at  the  shoulder  and  flexion  at  the 
elbow,  were  more  affected  than  any  others.  The  small 
muscles  of  the  hand  were  also  seriously  atrophied.  Pain, 
increased  by  passive  motion,  continued  to  be  a  prominent 


28- 

symptom.  The  patient  improved  gradually  for  six  weeks, 
but  then  was  seized  with  vomiting,  paralysis  of  the  sphinc- 
ters, rapid  pulse,  and  dysenteric  discharges,  attended  with 
high  fever,  and  died  after  a  two  weeks*  illness.  As  con- 
valescence advanced,  the  contrast  between  the  more  and  the 
less  damaged  muscles  became  steadily  more  marked. 

The  record  of  the  post-mortem  examination  mil  be  given 
in  connection  with  the  discussion  of  the  case. 

XXX. 

Rapid  Loss  of  Power  in  Arms  and  Legs,  followed  by  Wide- 
spread Muscular  Wasti?tg ;  later,  almost  Complete  Recov- 
ery in  Legs  and  Lmprovenunt  in  Arms.  No  Disorder  of 
Sensibility. 

The  patient  whose  condition  is  represented  by  the  accom- 
panying pictures  was  formerly  a  healthy,  vigorous  young 
farmer,  with  well-developed  chest  and  muscles. 

Six  years  before  his  first  visit  to  the  hospital  —  that  is, 
when  he  was  sixteen  years  old  —  he  was  working  hard  in 
the  hay-field,  one  day  in  August,  when  he  found  himself  get- 
ting feverish  and  suffering  from  a  severe  headache,  and  at 
the  same  time  observed  that  his  arms  and  hands  were 
becoming  rapidly  weak,  and  his  legs  also,  though  to  a  less 
degree.  Except  for  the  headache,  there  was  no  pain  ;  nor 
was  there  any  loss  of  sensibility.  He  got  home,  and  went 
to  bed,  but  was  very  soon  wholly  unable  to  use  his  arms  or 
legs.  None  of  the  muscles  supplied  by  the  cranial  nerves 
were  involved,  but  the  movements  of  the  head  were  some- 
what affected.    There  was  no  loss  of  control  of  the  sphincters. 

He  lay  in  bed  for  six  months,  gaining  considerably,  mean- 
while, in  the  use  of  the  legs,  and,  to  a  very  slight  degree, 
in  the  use  of  the  arms  and  hands ;  though,  for  practical 
purposes,  they  remained  almost  helpless. 

Before  the  end  of  a  year  he  could  walk  about ;  and  now, 
at  the  end  of  six  years,  his  legs  are  almost  as  well  as  ever, 
though  he  cannot  run,  or  walk  fast. 


Case  XXX. 


Case  XXX. 


Case  XXX. 


29 

The  muscles  of  the  shoulder-girdle,  arms,  and  hands,  are 
now  greatly  wasted,  especially  those  of  the  left  side.  The 
head  of  the  humerus  hangs  loose  in  the  socket.  The  flesh 
has  shrunk  away  from  the  shoulder-blades  and  the  cervical 
and  upper  dorsal  spines,  while  the  hand  muscles  are  almost 
wholly  gone,  especially  on  the  left  side,  so  that  the  carpal 
bones  stand  out  and  the  fingers  remain  semi-flexed  and 
contractured. 

Nevertheless,  slight  though  excessively  feeble  movements 
are  possible  in  many  of  the  wasted  muscles,  and  certain 
groups  —  such  as  the  long  flexors  of  the  fingers  —  are 
fairly  well  preserved. 

The  chest  expansion  is  impaired  but  not  lost.  The  legs 
are  muscular,  but  signs  of  wasting  are  seen  here  and  there, 
especially  in  the  left  quadriceps  group  of  muscles.  There  is 
no  disturbance  of  sensibility. 

General,  coarse  fibrillation  (myokymia)  is  seen  over  the 
back  and  arms.  Every  variation  of  electrical  reaction  is 
represented,  from  simple  quantitative  diminution  of  the 
faradic  irritability,  with  rather  slow  and  very  feeble  con- 
tractions, to  complete  R.  D.  Improvement  still  goes  on, 
though  extremely  slowly. 

XXXI. 

Wide-Spread  Paralysis  and  Atrophy  of  the  Limb  Muscles,  of 
Acute  Onsets  with  Fever. 

An  unmarried  woman,  twenty-nine  years  old,  employed  in 
a  shoe-shop,  presented  herself  in  January,  1901,  on  account 
of  almost  complete  loss  of  the  use  of  the  right  arm  at  the 
shoulder  and  elbow,  and  some  weakness  of  the  left  hand 
especially  as  regards  the  movement  of  the  thumb.  She 
described  the  onset  of  the  disease  as  follows  :  She  had  been 
well  up  to  the  previous  September,  when  she  had  been 
attacked  suddenly  with  severe  pain,  first  felt  in  the  back 
near  the  point  of  the  shoulder-blade,  then  in  the  head  and 
the  back  of  the  neck.     This  was  followed  at  once  by  fever, 


30 

which  confined  her  to  her  bed  for  two  days.  She  tried  to 
work  but  found  it  impossible,  the  pains  in  the  head  and 
back  of  the  neck  growing  constantly  worse.  Then  she  went 
to  bed  and  stayed  there  three  weeks,  though  there  was  not 
much  fever  after  the  first  few  days.  The  right  arm  had 
become  painful  very  early,  as  well  as  the  neck  and  back ;  and, 
at  the  same  time  with  the  onset  of  this  pain  in  the  arm,  or  a 
little  before  it,  the  muscles  there  became  extremely  weak. 
The  pain  was  mainly  in  the  shoulder  and  upper  arm,  where 
the  muscular  weakness  was  also  the  most  pronounced,  and 
it  was  increased  by  motion.  These  pains  lasted  three  weeks. 
For  some  time  there  was  a  sense  of  numbness  in  the  hands 
and  fingers,  but  this  became  gradually  less,  though  it  had 
not  wholly  disappeared  at  the  time  of  the  first  examination. 
The  right  leg  and  the  back  were  also  very  weak,  and  the 
right  leg  was  painful  from  the  knee  down  to  the  foot.  The 
left  hand  and  the  left  leg  were  affected  somewhat,  but  to  a 
less  degree. 

Physical  examination  gave  the  following  results :  As  re- 
gards the  right  arm,  there  was  a  marked  atrophy  of  the  supra- 
and  infra-spinatus,  the  deltoid,  the  triceps,  and  the  biceps, 
though  it  was  somewhat  masked  by  subcutaneous  fat.  The 
forearm  muscles  were  also  flabby,  especially  the  flexors.  Ab- 
duction at  the  shoulder  was  impossible,  although  fibres  of 
the  deltoid  could  be  felt  to  contract  when  the  effort  was 
made.  There  was  no  power  of  rotation  outward  or  in- 
ward at  the  shoulder.  When  the  arm  was  passively  raised, 
it  could  be  depressed  feebly  by  the  pectoralis  and  the  latis- 
simus  dorsi,  though  these  muscles  also  were  weak  and 
wasted.  The  shoulder-blades  could  be  approximated  fairly 
well  behind,  and  the  point  of  the  shoulder  raised,  though 
very  feebly.  The  erector-spinae  muscles  were  so  flabby  that 
the  fingers  could  be  pressed  in  deeply,  especially  on  the  left 
side.  The  right  arm  hung  a  little  low  at  the  shoulder, 
leaving  quite  a  space  between  the  head  of  the  humerus  and 
the  socket.     The  grasp  of  the  right  hand  was  fair,  though 


31 

weak.  The  thumb  lay  almost  on  the  plane  of  the  hand. 
Flexion  and  extension  at  the  elbow  were  possible,  though 
very  weak ;  but  flexion  seemed  to  be  done  almost  wholly  by 
the  supinator  longus,  the  biceps  and  triceps  contracting,  to 
be  sure,  but  too  feebly  to  accomplish  much.  The  left  arm 
was  in  a  similar  condition,  but  was  much  less  severely 
affected,  except  that  the  movements  of  the  left  thumb  were 
weaker  than  those  of  the  right.  All  motions  of  the  legs  and 
feet  were  possible,  but  there  were  indications  of  weakness 
here  and  there.  The  knee-jerks  were  present ;  but  that  of 
the  left  side  was  very  feeble,  while  that  of  the  right  side  was 
fairly  good.  The  sensibility  to  touch  seemed  to  be  every- 
where perfect.  The  faradic  reactions  were  greatly  dimin- 
ished, qualitatively  and  quantitatively,  even  in  the  moderately 
affected  muscles,  such  as  those  of  the  two  forearms,  the 
contractions  being  slow  and  feeble  and  much  less  marked 
than  would  be  expected  from  the  condition  of  the  functional 
activity.  There  was  well-marked  R.  D.  in  the  muscles 
most  affected.  There  was  no  tenderness  over  the  limbs; 
and  there  had  been  none,  she  said,  even  during  the  height 
of  the  disease,  except  at  the  right  shoulder  where  the 
muscles  were  most  strongly  affected.  Passive  motion  of  the 
limbs,  however,  brought  on  an  aching  which  would  last  for 
some  time. 

The  sphincters  were  unaffected. 

So  far  as  she  knew,  no  other  cases  had  been  observed  in 
the  neighborhood. 

Treatment  was  of  but  little  service,  and  improvement  was 
slow  and  imperfect. 

XXXII. 

Partial  Paralysis  of  all  Four  Limbs  ^  resulting  from  a 
Fall  on  the  Head, 

A  young,  vigorous  man  was  thrown  from  a  wagon,  Jan.  24, 
1872,  and  struck  on  the  head  and  shoulders.  He  was  at 
first  wholly  paralyzed,  but   after   the  end  of  four  days  he 


recovered  his  power  of  walking.  There  was  considerable 
paraesthesia  of  both  arms,  and,  at  first,  almost  complete 
paralysis,  the  right  being  more  affected  than  the  left.  At 
the  end  of  two  weeks  the  left  arm  had  recovered  its  strength, 
while  the  right  arm  was  better  but  had  not  wholly  recovered. 
At  the  time  of  the  first  examination,  which  was  a  few 
weeks  after  the  accident,  all  the  muscles  of  the  right  arm, 
both  above  and  below  the  elbow,  were  found  to  be  somewhat 
smaller  than  those  of  the  left.  Extension  of  the  fingers  was 
impossible,  and  the  electrical  examination  showed  that  the 
long  extensor  muscle  (extensor  com.  dig.)  could  not  be  made 
to  contract  by  the  faradic  current,  and  was  abnormally  sen- 
sitive to  the  galvanic  current  (R.  D.).  Extension  of  the 
carpus  was  not  wholly  lost.  The  fingers  were  somewhat 
bent  and  could  not  be  fully  straightened,  and  the  electrical 
irritability  of  the  interosseous  muscles  was  diminished 
though  not  lost.  All  the  other  movements  of  the  hand  and 
arm  were  possible,  though  more  or  less  weak.  The  reaction 
of  the  long  flexors  to  electricity  was  unimpaired,  and  likewise 
that  of  the  supinator  longus.  The  patient  was  seen  again 
twenty-eight  years  later,  and  it  was  found  that  no  consider- 
able improvement  in  the  use  of  the  arm  had  taken  place. 

XXXIII. 

'-''Numbness''^  and  Weakness  of  Arms  and  Legs  ^  with   General 
Nervous  Symptoms ^  following  a  Blow  on  the  Head. 

This  patient  was  a  man  of  sixty-eight,  of  good  habits,  but 
of  little  social  training.  In  the  course  of  his  work  as  janitor 
of  a  school  building,  he  was  struck  violently  on  the  right 
side  of  the  head,  in  February,  1900,  by  a  heavy  door,  blown 
to  by  the  wind.  For  a  number  of  days  nothing  in  particular 
was  complained  of  except  some  prostration.  Then  he  began 
to  be  annoyed  with  tinnitus  of  the  right  ear.  A  few  weeks 
later  he  began  to  have  numbness  of  the  fingers  of  both 
hands  and  considerable  weakness  both  of  the  arms  and  legs, 


33 

increasing  gradually.  He  also  fell  into  a  nervous  state,  so 
that  after  a  few  months  he  went  to  bed  and  stayed  there 
most  of  the  summer,  complaining  of  staggering  and  dizziness 
if  he  tried  to  walk,  and  able  to  use  his  hands  and  arms  but 
little. 

On  examination  eight  months  later,  he  was  found  with 
general  emaciation  but  no  localized  atrophy  or  paralysis. 
On  being  told  to  move  the  fingers,  he  showed  his  ability  to 
make  all  motions,  but  his  grasp  was  excessively  feeble, 
though  he  seemed  to  make  great  exertion.  On  encourage- 
ment the  extent  and  power  of  the  movements  were  consider- 
ably increased.  There  was  no  disorder  of  sensibility.  The 
fingers  seemed  to  have  become  stiff,  so  that  even  passive 
motion  was  impossible  to  the  extent  of  complete  flexion, 
and  when  this  was"  attempted  he  complained  loudly  of 
pain.  The  motions  of  the  right  shoulder  were  also  re- 
stricted to  passive  motion.  The  knee-jerk  was  exaggerated 
on  both  sides,  and  there  was  an  indication  of  ankle-clonus, 
which,  however,  could  not  be  obtained  when  the  muscles 
were  relaxed. 

XXXIV. 

Paralysis  and  Atrophy  of  the  Arm ;  Erb''s  Type. 

A  healthy  young  man  of  twenty-one  awoke  one  morning 
in  September  with  severe  headache  and  fever.  He  stayed 
in  bed  two  days,  but  his  symptoms  did  not  change.  Then  he 
tried  to  go  to  work,  though  feeling  weak  and  tremulous.  On 
the  third  day  he  woke  up  in  the  morning,  still  feverish  and 
prostrated,  and  then  for  the  first  time  he  found  himself  un- 
able to  move  the  right  arm  at  the  shoulder,  though  he  could 
flex  and  extend  the  forearm  at  the  elbow.  The  hand  was 
also  weak  and  nearly  helpless.  Again  he  lay  in  bed  for  two 
weeks,  during  part  of  which  time  his  headache  continued. 

There  has  been  no  pain  in  the  arm  at  any  time.  The 
left  arm  also  became  weak  at  the  same  time  with  the  right, 
though  to  a  much  less  degree.     For  two  weeks  he  could  not 


34 

raise  the  left  hand  above  the  head,  but  gradually  the 
muscles  of  that  arm  regained  their  strength  and  the  move- 
ments became  nearly  normal.  He  thinks  that  there  was  no 
real  loss  of  power  in  the  legs  except  what  would  be  accounted 
for  by  his  general  weakness. 

On  examination,  it  was  found  that  all  the  muscles  cover- 
ing the  right  shoulder  were  greatly  atrophied.  When  he 
raised  his  arm  the  scapula  moved  inward  toward  the  spine 
and  fell  off  from  the  side  of  the  chest  at  its  posterior  edge. 
All  the  muscles  of  the  upper  arm  were  also  considerably 
wasted,  and  likewise  all  the  intrinsic  muscles  of  the  hands. 
The  forearm  muscles  were  pretty  well  preserved.  The  tri- 
ceps were  very  weak,  and  the  biceps  also,  though  to  a  less 
degree. 

A  careful  electrical  examination  showed  a  diminution  of 
the  faradic  irritabihty  of  the  muscles,  corresponding  in  de- 
gree with  the  weakness  and  atrophy  which  they  respectively 
exhibited.  There  was  a  typical  R.  D.  of  the  thenar  and 
interosseous  muscles  of  the  right  hand,  and  a  partial  R.  D. 
of  the  deltoid. 

Under  careful  exercises  the  patient  improved  slowly,  but 
did  not  entirely  recover. 

XXXV. 

Paralysis  of  the  Left  Arm  ;  ErVs  Type. 

A  small  boy  of  seven  was  brought  to  me  in  March,  1897, 
on  account  of  weakness  and  awkwardness  of  the  left  arm. 
In  fact,  the  arm  was  seen  to  hang  limp  by  his  side  fully 
extended  and  rotated  inward,  so  that  under  ordinary  cir- 
cumstances the  knuckles  looked  forward. 

The  history  was  given  that  this  condition  was  noticed 
immediately  after  birth,  which  had  been  a  very  difficult  one, 
requiring  the  use  of  instruments.  The  head  and  neck  had 
been  greatly  bruised,  and  after  delivery  there  was  a  swelling 
"  like  a  small  cabbage  "  on  the  side  of  the  neck. 

On  closer  examination  it  was  found  that,  while  the  deltoid 


35 

and  the  pectoral  muscles  were  fairly  well  preserved,  there 
was  complete  paralysis  of  the  triceps,  and  of  the  extensors 
of  the  fingers  and  hands,  and  almost  complete  paralysis  of 
the  biceps.  The  intrinsic  muscles  of  the  hands  were  all 
paralyzed  and  wasted,  although  the  wasting  was,  in  a 
measure,  masked  by  the  subcutaneous  fat.  The  upper  arm 
hung  loosely  at  the  shoulder-joint  and  could  be  half  dis- 
located with  a  little  effort.  Besides  this  condition  there  was 
an  entire  loss  of  sensibihty  of  the  hand  except  in  the  dis- 
tribution of  the  median  nerve,  and,  even  when  this  area  was 
pricked,  the  feeling  which  was  excited  was  referred  to  the 
neighborhood  of  the  wrist  (compare  Case  VII.).  There 
were  scars  on  the  back  of  the  hand  and  on  the  ends  of  the 
fingers,  where  the  child  had  burned  himself  without  being 
aware  of  it.  This  impairment  of  sensibility  reached,  in 
some  degree,  to  the  elbow,  but  above  that  point  the  sensi- 
bility was  normal. 

« 

XXXVI. 

Pain  in  the  Arm  of  Long  Standing. 

In  June,  1895,  a  man  of  thirty,  a  teacher  in  a  commercial 
college,  came  for  advice  on  account  of  pain  or  rather  a  sense 
of  discomfort  and  distress  in  his  right  arm,  not  very  severe, 
but  so  annoying  that  it  had  obliged  him  or  induced  him  to 
give  up  his  pursuits  one  after  another,  even  to  that  of  riding 
the  bicycle,  of  which  he  had  been  very  fond.  This  pain 
had  begun  five  years  before,  the  exciting  cause  having 
apparently  been  excessive  use  of  the  arm  in  writing,  which 
at  the  time  brought  on  this  condition  of  excitability.  For  a 
long  time  he  had  had  massage  from  a  skilled  gymnast,  and 
under  this  he  had  improved  somewhat;  but  the  gain  was 
not  lasting,  and  he  was  finally  advised  by  his  physician  to 
give  up  his  work  and  live  on  a  farm.  At  the  time  of  his 
examination  it  was  all  he  could  do  to  write  even  a  line  a  day 
without  bringing  on  a  distressing  sensation,  first  in  the 
wrist,    then    in    the    muscles    just    below    the    elbow,    and 


36 

finally  in  the  shoulder  and  whole  right  side,  until  he  felt 
"  unnerved  "  all  over.  His  general  health  was  good,  but  he 
had  never  been  very  robust. 

Eight  weeks  previously  he  had  had  a  slight  irritation  of 
the  throat,  so  that  talking  was  uncomfortable ;  and  for  six  or 
seven  months  he  had  refrained  from  talking  almost  altogether. 

Eleven  years  before  his  first  examination  he  had  sprained 
his  ankle,  and  had  hobbled  around  for  a  long  time  with  a 
painful  and  sensitive  foot.  Finally,  he  came  to  the  conclu- 
sion that  he  must  get  well,  and,  consequently,  began  to  walk 
without  regard  to  the  pain.  Under  this  somewhat  heroic 
treatment  the  ankle  promptly  got  better. 

Physical  examination  showed  nothing  in  particular  except 
that  he  was  a  spare  but  fairly  muscular  man  with  an  anxious, 
tired  expression.  The  subsequent  history  of  the  case  will 
be  given  in  the  course  of  the  discussion. 

XXXVII. 
Fain  in  the  Right  Arm  and  Other  Symptoms, 

In  March,  1902,  a  lady  came  for  treatment  on  account  of 
severe  pain  in  the  right  arm  which  troubled  her  especially  at 
night.  The  area  to  which  this  was  referred  was  a  definite 
one,  and  occupied  the  inner  aspect  of  the  arm  from  the 
axilla  to  the  carpus.  The  pain  was  irregularly  intermittent 
in  course,  disappearing  and  then  coming  on  again  with 
intense  violence.  At  night  the  arm  felt  as  if  wires  were 
running  through  it,  she  said,  and  the  pain  was  "  something 
terrible,"  so  that  she  had  not  had  a  good  night's  rest  for  a 
year.  Occasionally  a  sensation,  described  not  as  a  pain, 
but  as  a  crawling  feeling,  runs  down  the  right  side  of  the 
chest  and  into  the  abdomen.  These  symptoms  began  gradu- 
ally more  than  a  year  ago. 

On  careful  examination  the  following  conditions  were 
found  :  — 

The   left   pupil   was    larger  than  the   right,   and  neither 


6/ 

responded  to  light,  while  both  contracted  with  efforts  of 
accommodation.  The  left  knee-jerk  was  also  greater  than 
the  right,  though  both  were  present.  There  was  some 
degree  of  impairment  of  sensibility  over  the  whole  right  side 
of  the  body,  but  over  the  painful  area  the  impairment 
reached  a  very  high  degree.  She  said  that  she  had  suffered 
so  much  from  pain  that  she  had  lost  twenty  pounds  in  weight 
within  the  last  year. 

XXXVIII. 

/Neuralgic  Pain  in  Arms ;  Paraplegia^  Remitting  and 
Exacerbatijig  by  Turns. 

A  laboring  man,  forty  years  old,  had  suffered  for  several 
weeks  from  severe  neuralgic  pains,  radiating  down  the  inner 
side  of  the  right  arm  and  into  the  little  and  ring  fingers. 
These  pains  extended  later  to  the  corresponding  area  of  the 
left  arm.  After  they  had  been  a  source  of  trouble  to  him 
for  a  few  days,  he  was  crossing  the  street  one  day  when  his 
knees  gave  way  and  he  fell  suddenly  to  the  ground.  On 
trying  to  rise,  he  found  he  had  almost  completely  lost  power 
in  his  legs,  while  at  the  same  time  he  felt  numb  and 
"  dead  "  below  the  waist.  He  thought  there  was,  perhaps, 
momentary  loss  of  consciousness.  For  the  next  few  days 
he  was  able  to  be  around  the  house  with  the  aid  of 
crutches,  but  grew  gradually  worse,  so  that  in  three  weeks 
his  legs  were  powerless  and  he  was  obliged  to  remain  in 
bed.  During  this  period  he  suffered  from  severe  pain  in 
his  arms  and  legs,  and  it  was  found  that  they  were  tender 
on  moderate  pressure. 

After  four  months  of  medical  treatment  he  began  to  im- 
prove. The  pain  lessened,  and  he  regained  some  power  in 
his  legs.  Suddenly  he  had  a  relapse  followed  by  another 
period  of  improvement,  and  this  sequence  occurred  once 
more,  two  or  three  months  later ;  but  the  final  improvement 
was  not  complete,  and  he  found  his  legs  getting  more  and 
more  rigid. 


38 

Ever  since  the  first  attack  there  had  been  more  or  less 
disturbance  of  micturition,  and  a  catheter  had  been  fre- 
quently used.  The  bowels  were  very  constipated.  There 
had  been  no  remission  in  the  pains  in  the  arms  for  several 
months  before  he  entered  the  hospital,  and  hypnotics  were 
used  almost  every  night  to  secure  sleep. 

Examination  showed  the  right  pupil  to  be  slightly  larger 
than  the  left,  but  that  both  reacted  normally  to  light. 

Tjiere  was  marked  atrophy  of  the  right  forearm  and  of 
the  intrinsic  muscles  of  the  right  hand,  with  diminished 
grasp. 

Sensibility  to  touch  and  pain  was  much  diminished  below 
the  second  rib  on  the  right  and  third  rib  on  the  left,  while 
temperature  sense  was  absent  over  these  areas. 

The  legs  were  in  a  state  of  spastic  paralysis.  The  patel- 
lar-reflexes  were  equal,  but  much  exaggerated.  The  Ba- 
bin ski-phenomenon  and  ankle-clonus  were  present  on  both 
sides. 

The  temperature  was  normal.  The  urine  examination 
showed  nothing  abnormal  except  the  presence  of  some 
bladder  elements  in  the  sediment. 

The  patient  denied  having  had  syphilis,  but  admitted  that 
he  had  had  gonorrhoea  several  years  previously.  Iodide  of 
potassium  was  given  in  increasing  doses,  and  resulted  in 
relief  of  pain  and  some  improvement  of  sensibility. 

XXXIX. 

Pain  in  a  Defi7iite  Area  of  one  Arm. 

One  morning  in  March,  1902,  a  laundress,  about  forty 
years  old,  came  to  me  complaining  of  severe  pain  in  the  left 
arm.  She  said  that  seven  weeks  previously  she  had  been 
confined  to  her  bed  for  three  weeks  with  pain  in  the  region 
of  the  left  shoulder,  which  was  increased  by  movement  of 
the  arm  or  by  inclining  the  head  toward  the  right.  The 
shoulder  was  not  red  or  swollen,  but  was  tender  on  press- 


39 


Case  XXXIX. 
Showing  Area  of  Anaesthesia. 


40 


Case   XXXIX. 
Showing  Area  of  Anaesthesia. 


41 

ure.  The  pain  had  not  been  so  severe  in  the  shoulder 
during  the  last  four  weeks ;  and  she  had  been  able  to  be 
about  the  house,  but  could  do  no  work  on  account  of  sharp, 
cutting  flashes  which  radiated  down  the  outer  side  of  the 
arm  and  into  the  thumb  and  index  finger.  This  had  kept 
her  awake  for  so  many  nights  that  she  felt  thoroughly  ex- 
hausted. Besides  the  pain  there  was  a  "  numbness "  of 
the  affected  area,  which  had  been  present  from  the  first. 

This  patient  had  been  married  ten  or  fifteen  years,  and 
had  had  two  miscarriages  and  one  healthy  child.  She  used 
tea  in  moderation,  alcohol  not  at  all. 

Examination. —  The  head  is  held  inclined  toward  the  left 
shoulder  by  spasm  of  the  neck  muscles  of  that  side.  Any 
attempt  to  elevate  the  chin,  rotate  the  head,  or  bend  it  to  the 
right,  is  accompanied  by  intense  pain  in  the  arm.  There 
is  no  tenderness  along  the  spine,  and  no  kyphosis.  The 
heart  and  lungs  are  normal. 

Tests  for  disturbance  of  sensibility  show  complete  anaes- 
thesia and  analgesia  with  loss  of  thermal  sense,  over  the 
areas  indicated  in  figure  by  ruled  lines,  while  sense  of  posi- 
tion is  absent  for  the  left  thumb  and  index  finger.  The 
grasp  of  the  left  hand  is  much  weaker  than  that  of  the  right, 
the  dynamometer  showing  L  =  lo,  R  =  42.  There  is  con- 
siderable tenderness  down  the  outer  aspect  of  the  left  arm, 
not  limited  to  nerve  trunks.  The  patellar-reflexes  are 
normal. 

The  patient  was  fitted  with  a  high,  stiff  collar  which  sup- 
ported and  immobilized  the  head  as  much  as  possible.  In 
iwo  weeks  she  was  much  improved,  and  in  six  weeks  the 
pain  was  entirely  gone,  though  the  disturbance  in  sensibility 
still  remained. 


42 


XL. 

Injury  in  Cervical  Region  ;  Paresis  of  Limbs  and  other  Serious 

Symptoms ;   Sudden  Improvement  at  the  End  of  Fifteen 

Months. 

[Case  reported  by  Dr.  G.  L.  Walton.] 

A.  W.,  cook,  single,  thirty-five  years  of  age,  was  admitted 
to  the  Massachusetts  General  Hospital  in  the  service  of 
Dr.  J.  C.  Warren,  with  whom  I  saw  him,  from  time  to  time, 
during  his  stay.  He  was  seen  also  by  a  number  of  other 
physicians,  including  Dr.  J.  J.  Putnam  and  Dr.  M.  H. 
Richardson. 

The  history  was  as  follows:  On  Jan.  3,  1885,  he  fell 
down  a  flight  of  steps,  backwards,  striking  his  neck  on  the 
edge  of  a  door-post.  His  head  was  thrown  forward  with  the 
chin  elevated,  in  which  position  it  remained  up  to  the  time 
of  entrance.  He  lost  consciousness  for  six  hours,  and  re- 
mained in  bed  about  one  month,  complaining  principally, 
apart  from  the  displacement  and  rigidity  of  the  head,  of 
general  weakness,  numbness,  and  stiffness  of  the  legs  when 
getting  up,  and  a  slight  twitching  in  the  hands.  There  was 
no  trouble  in  breathing,  from  the  first.  He  entered  the  hos- 
pital March  30,  about  two  months  after  the  accident.  He 
complained  at  that  time  of  pain  in  the  shoulders  and  across 
the  back,  and  of  gradually  increasing  weakness.  The  head 
was  projected  forward  with  the  chin  elevated.  There  was  a 
marked  prominence  over  the  fourth  cervical  vertebra ;  above 
this  point  the  spinous  processes  of  the  vertebrae  were  less 
prominent  than  normal.  Digital  examination  of  the  throat 
showed  a  projection  in  the  posterior  pharynx.  The  patient 
was  able  to  walk,  but  with  a  spastic  gait.  Ankle  clonus  was 
present.  The  patellar  reflex  was  so  greatly  exaggerated  that 
tapping  the  tendon  produced  a  continuous  clonus.  Respira- 
tion was  normal.  There  was  at  that  time  no  objective  dis- 
turbance of  sensation.  The  grasp  was  weak  on  both  sides, 
as  well  as  extension  of  the  wrist.     The  supinator  longus  was 


43 

strong,  as  were  the  muscles  of  the  upper  arm,  excepting  the 
triceps  on  the  left,  which  were  feeble.  There  was  no  marked 
reflex  in  the  arm.  Every  attempt  at  movement  of  the  legs 
caused  tremor.  Flexion  and  extension  of  the  thigh  were  fair 
on  both  sides.  The  tibialis  anticus  and  gastrocnemius  were 
moderately  strong,  the  peroneal  muscles  weak.  The  legs 
were  rigid.  There  was  no  atrophy  or  coldness.  The 
plantar,  abdominal,  and  cremaster  reflexes  were  normal. 
The  pupils  were  equal,  and  reacted  to  light.  There  was 
nothing  abnormal  about  the  face.  The  respiration  was  20, 
the  pulse  86,  the  temperature  normal. 

Three  days  after,  an  operation  was  undertaken.  The  pa- 
tient was  etherized.  The  cervical  vertebrae  were  extended 
by  pulling  the  head  in  one  direction  and  the  body  in  the  op- 
posite. No  distinct  snap  was  felt,  but  the  prominence  of  the 
vertebrae  was  considerably  diminished.  The  neck  was  held 
in  position  by  bandaging  the  head  and  body  to  a  broad 
leather  splint.  The  second  day  after  the  operation  there 
appeared  to  be  an  improvement  in  the  patient's  condition. 
The  grasp  was  stronger,  and  the  ankle  clonus  less  marked. 
On  the  fourth  day  the  apparatus  was  omitted.  On  the  sixth 
day  careful  examination  showed  no  improvement  over  liis 
previous  condition.  On  the  sixteenth  day  the  patient  was 
gradually  losing  ground:  he  was  growing  feebler,  and  the 
cervical  prominence,  together  with  the  peculiar  manner  of 
holding  the  head,  had  returned.  Sensation  was  impaired  in 
legs  and  arms.  One  month  later  the  condition  was  not 
changed,  excepting  in  the  direction  of  an  increased  feeble- 
ness. After  two  months  the  patient  could  not  stand  on  his 
feet  without  assistance.  After  two  and  one-half  months  the 
head  of  the  bed  was  elevated,  and  extension  was  applied  to 
the  neck  with  halter  and  weights.  This  apparatus  was  re- 
moved five  days  later.  At  the  end  of  three  months  the 
patient  was  gradually  failing.  Bladder  symptoms  had 
appeared,  in  the  form  of  retention.  There  was  tonic  spasm 
of  the  legs.     Sensation  in  the  legs  was  lost  to  the  groin,  and 


44 

in  the  arms  to  the  middle  of  the  upper  arm.  Four  months 
after  operation  the  patient  was  completely  helpless,  and  un- 
able to  grasp  anything  firmly  in  the  hand.  He  was  much 
troubled  by  constipation,  and  suffered  at  intervals  from  re- 
tention, which  required  the  use  of  the  catheter.  At  the  end 
of  four  months  and  one-half,  further  surgical  interference 
was  considered  unadvisable  ;  and  he  was  discharged  from 
the  hospital,  but  was  allowed  to  remain  at  the  Convales- 
cents' Home  until  ten  months  after  the  accident,  when  he 
was  taken  to  the  almshouse,  where  he  remained  without 
improvement  for  three  months  longer.  At  the  end  of  this 
time  —  that  is,  about  fifteen  months  after  the  accident,  while 
taking  a  lukewarm  bath,  ice-cold  water  being  meantime 
thrown  upon  his  back  by  a  syringe  —  he  suddenly  felt  a  sen- 
sation like  an  electric  shock.  He  was  rubbed  down  and  put 
to  bed,  and  the  galvanic  current  was  applied  to  all  ex- 
tremities. 

The  next  morning  he  found  he  could  rise  in  bed.  Cold 
water  was  thrown,  after  this,  in  large  quantities  on  his  back 
every  other  day,  after  which  the  galvanic  battery  was  ap- 
plied. Improvement  was  steady  and  rapid,  and  within  a 
month  he  was  at  work  in  a  restaurant.  The  head  had 
become  gradually  replaced  during  this  time.  No  further 
symptoms  appeared. 

The  patient  was  carefully  examined  three  years  after  the 
accident.  The  gait  was  normal  and  free,  the  tendon  reflex 
was  normal.  There  was  no  rigidity  nor  ankle-clonus.  All 
movements  of  the  extremities  were  perfect,  and  the  lightest 
touch  was  everywhere  felt.  The  head  was  held  rather 
stiffly,  canted  slightly  to  tlie  left,  with  the  chin  elevated  and 
turned  to  the  right,  the  whole  head  being  held  somewhat 
forward.  The  fourth  and  fifth  cervical  vertebrae  were  rather 
prominent,  though  no  more  than  is  sometimes  found  in 
health.  The  spinous  processes  above  were  distinctly  felt. 
There  was  no  prominence  in  the  posterior  pharynx. 


(i^x.'jXw^ 


14^ 


45 


XLI. 

Entire  Paralysis  of  the  Legs,  etc.,  of  Sudden  Onset, 
following  Injury. 

This  patient  was  a  young  man  of  twenty-five,  a  splendid, 
athletic-looking  fellow.  Two  weeks  before  he  was  examined, 
he  went  bathing  off  a  pier  with  his  friends,  and  dove  three 
successive  times  into  the  water.  The  second  time  he  struck 
rather  flat,  and  felt  as  if  he  had  sprained  his  back  a  little ; 
but  the  effects  of  this  seemed  to  have  passed  away  before  he 
reached  the  surface  of  the  water.  The  third  time  he  dove 
without  difficulty;  but,  on  trying  to  turn  in  the  water  to  rise 
to  the  top,  he  found,  to  his  horror,  that  his  legs  would  not 
move,  so  that  he  had  to  paddle  himself  up  with  his  hands 
alone.  Ever  since  that  moment  his  legs  have  been  para- 
lyzed, and  not  only  that,  but  the  bladder  and  rectum  have 
been  in  the  same  condition.  No  material  improvement  has 
taken  place,  but,  fortunately,  there  has  been  no  pain  at  any 
time. 

The  bodily  temperature  was  io3°F.  the  day  after  the  in- 
jury, but  had  fallen  to  99°  by  the  end  of  the  first  week. 
Then  it  rose  for  a  while,  and  by  the  end  of  the  second  week 
it  was  103°.  This  was  perhaps  due  to  the  fact  that  gangre- 
nous sloughs  had  formed  on  the  heels.  The  knee-jerks  were 
absent  both  at  first  and  at  the  end  of  the  second  week,  and 
presumably  later.  The  sensibility  of  the  skin  was  lost  for 
contact  and  pricking,  from  the  third  rib  down ;  and  the  line 
of  demarcation  went  round  the  chest  at  an  angle  with  the 
ribs,  perpendicularly  to  the  axis  of  the  body.  Not  only  this, 
but  there  was  an  area  of  anaesthesia  along  the  inner  surface 
of  the  left  upper  arm  and  forearm  down  as  far  as  the  hand, 
and  impairment  of  the  sensibility  over  the  same  area  of  the 
right  arm.  He  was  not  himself  aware  of  this  change  in  sen- 
sibility of  the  arms,  though  he  had  noticed  that'  his  left  arm 
"went  to  sleep"  sometimes  without  apparent  cause.  The 
motions  of  the  arms  in  general  were  good,  but  he   could  not 


46 

easily  touch  his  Httle  finger  and  thumb  nor  fully  extend  the 
fingers,  and  the  interosseous  muscles  were  absolutely  wasted. 
Incomplete  priapism  had  been  present  from  the  first.  As 
time  went  on,  these  conditions  remained  for  the  most  part 
unchanged  or  became  intensified.  The  use  of  the  arms 
being  preserved,  he  was  able  to  get  about  with  a  rolling- 
chair,  and  to  employ  himself  quite  actively. 

XLII. 

Paraplegia  of  the  Legs  and  Many  Other  Nervous  Symptoms^ 
following  a  Slight  Accident. 

On  Dec.  7,  1882,  a  man  forty-nine  years  old  was  trav- 
elling in  a  train  which  met  with  a  slight  accident,  through 
which  its  course  was  suddenly  arrested.  The  patient  was 
sitting  in  the  front  part  of  his  car,  with  his  face  toward  the  en- 
gine, not  suspecting  any  mischance,  when  he  found  himself 
thrown  violently  forward  toward  the  seat  before  him,  and  then 
back  upon  his  own  seat.  The  cushion  of  his  seat  had  been 
by  this  time  displaced  by  the  jerk,  and  the  patient  struck 
the  edge  of  it  with  his  back,  and  then  came  down  hard  onto 
the  floor  and  for  a  moment  was  slightly  stunned  so  that  he 
did  not  know  where  he  was.  He  was  helped  out  of  the  car, 
suffering  a  good  deal  of  pain  in  his  back,  but,  nevertheless, 
decided  to  go  on  with  his  journey,  although  feeling  faint  and 
sick.  On  arriving  at  his  destination,  he  was  nauseated  and 
vomited,  but  pulled  himself  together,  did  his  business,  and 
returned  home,  and  the  next  day  he  went  to  his  office, 
although  weak  and  miserable  and  complaining  of  pain  in 
the  back  and  back  of  the  head.  His  feet  and  hands  felt 
constantly  cold,  and  he  had  a  strange  sensation  running 
down  through  the  arms.  He  also  felt  gloomy  and  depressed-,: 
and  at  times  would  burst  into  tears  and  exhibit  signs  of 
great  nervousness.  His  sleep  at  night  was  poor  and  dis- 
turbed by  hallucinations,  and,  as  time  went  on,  he  lost  color 
and  strength.  The  temperature  was,  for  a  time,  rather 
below  normal  (97°  to  qS^F.),  and  the  pulse  slow  (60). 


47 

One  morning,  about  a  month  after  the  accident,  while  the 
patient  was  stiil  in  this  miserable  condition  and,  indeed,  still 
growing  worse,  he  found  when  he  tried  to  get  out  of  bed, 
that  he  could  not  stand.  An  examination  that  evening  re- 
vealed the  following  conditions  :  — 

The  voluntary  motion  of  the  legs  was  greatly  impaired, 
but  not  lost  for  any  given  movement.  He  could  draw  them 
slowly  up  while  lying  in  bed,  and  push  them  slowly  down ; 
but  he  could  not  turn  over  in  bed.  The  motions  that  he 
did  make  were  jerky  and  uncertain  in  character.  The  sen- 
sibility of  the  skin  over  the  legs  below  the  knee  was  very 
much  diminished,  so  that  a  pin  could  be  thrust  through  the 
skin  without  causing  pain,  although  it  did  cause  a  sensation 
as  if  of  shght  pinching.  Light  touch  of  the  finger  was  not 
felt,  but  deep  pressure  was  everywhere  noticed.  Above  the 
knees  the  sensibility  was  good,  and  the  change  from  the  sen- 
sitive to  the  insensitive  areas  was  fairly  abrupt. 

Any  jarring  of  the  legs  during  the  examination  made  the 
patient  cry  out  nervously  with  pain,  which  was  generally 
referred  to  the  back.  The  muscles  of  the  legs  were  moder- 
ately rigid,  but  yet  there  was  no  involuntary  jerking  at  night 
and  the  knee-jerks  were  not  greatly  increased.  The  im- 
pairment of  sensibility  was  more  complete  over  the  right  leg 
than  over  the  left,  and  not  only  this  but  the  sensibility  of 
the  right  arm  and  right  side  of  the  face  were  also  much 
below  the  normal,  and  the  field  of  vision  of  both  eyes  was 
diminished  toward  the  right.  The  hearing  of  the  right  ear 
was  also  less  good  than  that  of  the  left,  both  for  air-conduc- 
tion and  for  bone-conduction.  At  first  all  these  signs 
increased  in  severity,  so  that  after  a  few  days  the  patient 
could  scarcely  move  the  legs  at  all.  Yet  even  then  it  was 
noticeable  that  when  the  leg  was  raised  in  air  by  the  hand 
and  then  the  hand  removed,  it  would  not  drop  at  once  onto 
the  bed.  The  nervous  condition  remained  the  same,  and 
the  general  nutrition  suffered  greatly.  There  was  no  dis- 
turbance of  micturition,  but  the  quantity  of  the  urine  was 


48 

very  much  diminished,  as  indeed  it  had  been,  to  a  consider- 
able extent,  ever  since  the  accident,  while  the  desire  for 
micturition  was  greatly  lessened. 

The  faradic  reaction  of  the  muscles  of  the  legs  remained 
wholly  unimpaired,  but  the  patient  did  not  feel  the  con- 
traction of  the  muscles  below  the  knee  nor  the  stimulation 
of  the  skin  with  a  wire  brush  attached  to  the  faradic  battery. 

By  the  end  of  the  week  after  the  onset  of  the  paraplegia, 
he  was  able  to  walk  about  with  crutches ;  but,  when  he  did 
so,  the  right  leg  dragged  on  the  ground,  not  being  moved 
even  at  the  hip  joint,  whereas  the  left  leg  had  by  that  time 
recovered  a  certain  amount  of  strength.  Finally,  the  patient 
abandoned  his  crutches,  but  not  until  after  two  years  had 
passed ;  and,  when  examined  at  the  end  of  eleven  years,  he 
was  still  pale,  weak,  and  miserable,  though  not  paralyzed. 

XLIII. 

Paraplegia. 

A  girl  of  twelve  was  attacked  while  at  church  by  severe 
pains  about  the  waist,  rapidly  increasing  in  severity,  together 
with  sensations  as  of  approaching  loss  of  power  in  the  legs. 
In  walking  home,  the  limbs  were  weak  and  dragged.  Within 
four  hours  there  had  developed  complete  paralysis  —  ac- 
cording to  the  patient  a  flaccid  paralysis  —  of  motion  and 
sensation  in  legs  and  lower  trunk.  Involuntary  discharges  of 
urine  and  fseces  occurred.  There  was  no  essential  change 
for  four  weeks,  though  there  was  a  slight  return  of  bladder 
sensations,  but  shortly  aftersvards  there  developed  a  bed- 
sore on  the  right  thigh  (right  decubitus  up  to  that  time), 
followed  by  others  on  left  thigh  and  sacrum,  in  accordance 
with  change  of  position  in  bed.  These  healed  successively, 
but  at  the  time  of  examination  —  five  months  after  onset — 
their  sites  were  still  marked  by  deep  eschars  and  reddenings. 
There  has  been  slow  but  continuous  improvement  as  to  sen- 
sation and  sphincters,  and  the  status  is  as  follows  :  — - 


49 

Slight  general  emaciation  and  small  amount  of  atrophy  of 
leg  muscles.  Thighs  adducted  so  strongly  as  to  be  partly 
crossed ;  legs  flexed  on  thighs,  and  both  held  in  this 
position  by  firm  contractures,  which  require  considerable 
force  for  their  reduction.  Any  sudden  passive  motion  or 
jar  throws  the  legs  into  brisk  spasm,  the  left  especially  tend- 
ing to  assume  a  position  of  full  extension,  with  foot  flexed. 
These  reflex  movements  are  sometimes  so  extensive  as  to 
involve  the  trunk. 

Voluntary  motion  of  legs  and  lower  trunk  is  lost,  and 
it  is  only  with  difficulty  that  the  patient  turns  herself  in  bed. 

As  to  sensibility,  it  is  doubtful  if  there  is  any  absolute  loss, 
either  tactile  or  for  pain  ;  but  there  is  very  marked  impairment 
up  to  the  nipples  in  front,  and  on  the  back  to  the  ninth 
thoracic  spine  on  the  right,  and  to  the  sixth  on  the  left.  At 
these  levels  appears  suddenly  a  narrow  zone  of  hyperaes- 
thesia,  beyond  which  the  sensation  is  normal.  The  impair- 
ment is  decidedly  greater  over  the  legs  than  over  the  trunk. 

Reflexes:  On  account  of  spasm  the  knee-jerks  could 
not  be  examined.  Plantars :  typical  Babinski  left,  no 
reflex  on  right.  Marked  ankle-clonus  right  and  left.  The 
bladder  becomes  distended,  with  subsequent  involuntary 
dribbling,  unless  the  patient  is  catheterized.  There  is  some 
pus  in  the  urine,  showing  a  tendency  to  decrease  in  amount 
under  treatment. 

XLIV. 

Paraplegia  of  Jicute  Onset,  in  an  Elderly  Lady. 

A  lady  of  sixty-eight,  living  in  comfortable  circumstances 
and  with  a  record  of  good  health,  was  suddenly  attacked, 
without  apparent  cause,  with  a  sharp  pain  in  the  back,  and 
then,  to  some  extent,  in  the  legs  below  the  knees.  Almost 
at  the  same  time  she  felt  her  legs  getting  weak,  and  in  a  few 
hours  there  was  complete  paralysis  of  the  legs  for  both 
sensation  and  motion.  The  temperature  was  not  taken  at 
the  first  visit,  but  ever  since  then  had  been  normal.     The 


so 

pain  disappeared  with  the  onset  of  the  paralysis.  All  the 
reflexes  were  found  to  be  lacking  from  the  first.  An  exam- 
ination made  on  the  day  after  the  onset  showed  a  complete 
absence  of  cutaneous  sensibility  for  all  parts  below  the  groin, 
except  over  the  front  and  inner  surfaces  of  the  thighs.  In 
these  areas,  and  over  the  abdomen  as  high  as  the  umbilicus, 
the  sensibility  was  considerably  impaired,  but  not  wholly 
lost.  Later  there  was  slight  improvement  in  the  tactile 
sensibility,  but  none  as  regards  pain  sense.  Hot  and  cold 
objects  excited  a  vague  feeling,  but  she  could  not  discrimi- 
nate between  them.  As  time  went  on,  all  the  muscles  of  the 
legs  became  considerably  wasted.  There  was  incontinence 
of  urine  and  faeces.  No  essential  change  took  place  later  in 
the  patient's  condition,  and  she  died  in  the  following  year. 
There  was  no  post-mortem  examination. 

XLV. 

Progressive  Paraplegia :  Recovery. 

In  July,  1 89 1,  a  physician's  advice  was  sought  by  a  single 
man,  thirty-five  years  old,  on  account  of  difficulty  in  the  use 
of  the  legs,  so  great  that  he  was  confined  to  the  chair.  He 
stated  that  he  had  been  well  up  to  the  previous  January, 
when  he  first  noticed  a  "  numbness,,"  on  the  outer  side  of 
one  foot,  which  he  attributeoto  having  walked  barefoot  dur- 
ing a  boating  trip  in  Florida. 

At  this  same  period  he  had  had  a  headache  for  a  week, 
which  troubled  him  only  at  night,  but  was  then  so  severe  as  f 
to  keep  him  awake. 

In  the  latter  part  of  March  he  had  begun  to  find  walkm^y 
difficult.     In  April  severe   £ains  in  the  back   came  on,  so|» 
severe  that  one  night  he  tore  his  sheet  with  his  teeth  in  des- J* 
peration.     One  physician  in  good  standing  told  him  he  had] 
muscular  rheumatism,  another    said  it  was  the  "  grippe  ";^^ 
and  thus  precious  time  was  lost. 

Meantime   the    "  numbness  "  had     spread   ups^ards,   the 


(?a^  i,\y 


TTT    Ok©      *P-->v«»«*v-_  .    5>_/|«^*-'^ 


51 

right  foot  and  leg  had  become  almost  helpless,  and  the  left 
was  getting  weak.  Early  in  June  a  third  physician  again  ^ 
diagnosticated  muscular  rheumatism,  and  gave  K  I  grs.  X.,  ' 
t.  i.  d.,  but  later,  perhaps  from  a  change  in  diagnosis,  in- 
creased the  dose  to  grs.  XXX.  t.  i.  d.,  by  which,  perhaps, 
the  pain  was  relieved,  though  the  paralysis  continued  to 
increase,  and  a  girdle_serisation  developed.  The  bladder 
control  was  slightly  impaired.  A  physical  examination  gave 
the  following  results :  The  motions  which  were  lost  were 
those  at  the  right  ankle,  and  those  involved  in  drawing  up 
the  right  leg  toward  the  body.  All  other  motions  were  pre- 
served, on  both  sides,  including  those  of  the  toes,  but  all 
were  excessively  feeble,  those  of  the  right  leg  more  so  than 
those  of  the  left. 

The  cutaneous  sensibility  was  much  better  for  the  right 
leg  than  for  the  left,  as  regards  contact,  pricking,  and  tem- 
perature ;  and,  in  fact,  the  right  leg  was  hyperaesthetic  for 
pricking.  On  the  other  hand,  the  sense  of  position  was 
more  impaired  for  the  right  leg  than  for  the  left. 

The  knee-jerks  were  exaggerated  on  both  sides,  especially 
the  right,  and  ankle-clonus  was  present. 

The  patient  admitted  gonorrhoea  several  years  before,  but 
denied  knowledge  of  chancre.  A  typical  syphilitic  psoriasis 
was,  however,  present  on  the  palms  and  soles. 

Treatment. —  He  was  told  to  increase  the  potassium  iodide 
rapidly  to  300  grains  daily,  and  was  given  mercurial  oint- 
ment, one  drachm  daily,  by  inunction,  for  a  short  period. 

Course. —  Steady  improvement  and  almost  complete  recov- 
ery, except  for  slight  stiffness  and  awkwardness  of  the  right 
leg,  andLloss  _of  sexual  power,  which  still  remained  even  sev- 
eral years  later. 

The  treatment  has  been  continued,  in  a  modified  form, 
most  of  the  time  ever  since. 


52 


XL  VI. 

Paraplegia  of  Sensation  and  Motion. 

A  young  man  of  twenty-eight,  unmarried,  had  always  been 
well  and  vigorous  until  three  weeks  before  he  consulted  a 
physician.  He  had  had  a  venereal  sore,  without  secondary 
symptoms,  and  there  was  some  tuberculosis  in  the  family. 
Three  weeks  before  he  sent  for  the  physician  he  began  to 
have  numbness  in  the  soles  of  the  feet,  and  this  had  slowly 
crept  up  the  legs.  There  was  no  prickling,  but  rather  a 
feeling  of  compression.  At  about  the  same  time  he  began  to 
have  trouble  in  passing  water,  which  increased  so  that  for 
three  days  a  catheter  had  to  be  used,  and  its  use  has  been 
continued.  He  was  able  to  walk  a  short  distance  up  to 
within  three  days.  Now  he  is  confined  to  his  bed,  and  has 
no  control  of  his  legs  nor  power  to  raise  them  from  the  bed. 
For  a  week  he  has  had  night  sweats.  The  tactile  sensibil- 
ity is  diminished  up  to  the  umbilicus ;  the  other  forms  of 
sensibility  are  fairly  good.  The  legs  are  weak,  and  the 
power  to  co-ordinate  movements  in  them  is  much  diminished. 
He  cannot  stand  without  support,  and  closing  his  eyes  in- 
creases his  difficulty  in  standing.  The  electrical  reactions 
are  normal.  The  plantar  reflex  is  diminished  ;  the  abdomi- 
nal and  cremaster  reflexes  are  absent.  The  knee-jerks  are 
lively,  and  in  the  left  leg  there  is  a  tendency  to  ankle-clonus. 


XLVII. 

Paraplegia  of  Legs  after  a  Fall. 

A  man  twenty-eight  years  old  fell  from  a  second  story 
window  to  the  ground,  while  on  a  drunken  spree,  and  was 
unable  to  get  up  on  account  of  loss  of  power  in  both  legs. 
It  was  not  known  what  part  of  the  body  received  the  brunt 
of  the  fall,  but  there  was  a  large  bruise  on  the  top  of  his 
head. 


53 


t 


Case  XLVII. 
(Before  Operation.)     Showing  Area  of  Anaesthesia. 


54 


Case   XLVII. 
(Before  Operation.)     Showing  Area  of  Anaesthesia. 


55 


Case   XLVII. 
(After  Operation.)     Showing  Area  of  Anaesthesia. 


56 


Case  XLVII. 
(After  Operation.)     Showing  Area  of  Anaesthesia. 


57 

The  mental  condition  was  somewhat  confused,  but  whether 
from  the  fall  or  as  a  result  of  alcohol  could  not  be  deter- 
mined. The  patient  complained  constantly,  however,  of  se- 
vere pain  in  the  small  of  the  back.  The  pupils  were  normal 
in  size,  equal,  and  reacted  well  to  light.  The  arms  were 
unaffected.  The  legs  were  paralyzed  ;  and  there  was  loss  of 
sensation,  as  indicated  in  the  diagram.  The  patellar  and 
plantar  reflexes  were  absent,  and  incontinence  of  urine  and 
faeces  was  present.  The  abdomen  was  rigid,  but  not  t^^n- 
der.  The  first  lumbar  vertebra  was  prominent,  and  mode- 
rate pressure  here  caused  pain.  The  temperature  was 
slightly  elevated,  but  the  pulse  of  good  quality,  and  not  very 
rapid. 

Operation  was  considered  advisable,  and  was  performed 
the  following  day.  Several  spicules  of  broken  bone  were  re- 
moved ;  but  the  dura  which  was  thus  exposed  seemed  to  be 
normal,  and  was  not  bulging.  On  incision  of  the  dura  there 
was  an  escape  of  cerebro-spinal  fluid,  but  no  blood  nor  clots. 

Recovery  from  the  operation  was  good,  but  for  several 
weeks  the  patient  suffered  from  pains  in  the  legs.  There 
was  some  improvement  in  sensation  on  the  second  day,  but 
none  afterward.  Five  months  later  some  motion  of  the  left 
foot  was  possible,  but,  in  general,  the  paralysis  remained  the 
same,  and  the  patient  was  able  to  get  around  only  by  the  aid 
of  a  wheel-chair. 

XLVIII. 

Spastic  Rigidity  of  the  Legs,  of  Gradual  Onset. 

This  is  the  case  of  a  male  patient,  unmarried,  and  fifty 
years  old.  The  chief  complaint  at  the  time  of  the  first  ex- 
amination was  difficulty  in  walking  on  account  of  rigidity  of 
the  legs,  which  was  so  great  that  he  could  only  progress  by 
very  short  steps.  He  complained  also  of  a  continuous  burn- 
ing sensation  in  the  right  groin,  a  sense  of  coldness  in  the 
buttocks,  and  a  numb,  tickling  feeling  in  the  soles  of  the 
feet ;  and  he  asserted  that,  when  he  put  his  feet  into  warm 


58 

water,  he  could  not  easily  recognize  the  temperature.  Mic- 
turition was  increased  in  frequency,  and  there  was  a  slight 
loss  of  bladder  control.  There  was  no  girdle  sensation,  and 
the  hands  were  unaffected.  There  were  no  symptoms  ref- 
erable to  cranial-nerve  disorders  except  that  his  hearing 
had  become  somewhat  impaired.  Twenty  years  before  he 
had  had  a  syphilitic  infection,  for  which  he  had  had  thorough 
treatment  in  Germany.  The  difficulty  in  walking  had  begun 
two  years  before  the  first  examination,  and  the  motor  symp- 
toms had  preceded  the  sensory  symptoms  by  a  considerable 
time,  and  continued  to  form  the  most  prominent  and  impor- 
tant element  in  the  case,  the  sensory  disorders  being  rela- 
tively insignificant  throughout. 

On  physical  examination  there  was  found,  besides  the 
symptoms  above  noted,  an  exaggeration  of  the  knee-jerk  on 
both  sides,  and  ankle-clonus  on  the  right  side ;  also,  very 
slight  diffuse  impairment  of  sensibility.  In  spite  of  all  treat- 
ment the  patient  grew  gradually  worse  and  became  wholly 
paralyzed  in  the  legs,  which  remained,  however,  in  a  spastic 
and  contracted  state.  The  girdle  sensation  became  also 
more  marked.     Thorough  specific  treatment  was  unavailing. 

XLIX. 

Increasing  Weakness  of  Both  Legs,  associated  with  Parcesthesia 
and  Sense  of  Coldness. 

The  patient  is  a  married  man  of  forty-five,  of  good  habits 
and  free  from  signs  of  specific  disease.  The  weakness  of 
the  legs  began  about  five  months  ago,  and  has  been, of  very 
slow  increase,  though  now  he  walks  with  considerable  dif- 
ficulty even  with  the  aid  of  a  crutch.  The  weakness  and 
also  the  numbness  are  worse  on  the  right  side  than  on  the 
left.  The  sphincters  are  not  paralyzed.  Shortly  before  these 
symptoms  began  the  patient  was  troubled  with  a  deep- 
seated  pain  through  the  right  half  of  his  chest,  and  for  the 
past  five  months  there  has  also  been  a  peculiar  sensation 


59 

across  the  abdomen  from  time  to  time.  The  legs  tend  to 
draw  up  and  jerk  involuntarily,  even  when  the  patient  is  at 
rest.  His  health  has  never  been  very  good.  He  was  a 
seven  months'  child,  and  very  small  at  birth.  Throughout 
his  infancy  he  was  very  delicate  and  he  has  never  been 
robust,  though  looking  well,  and  able  to  serve  in  the  army 
for  several  years  during  the  war. 

On  physical  examination  it  is  found  that  the  nutrition  of 
the  muscles  of  the  legs  is  good.  The  sensibility  to  contact 
and  pricking  is  slightly  impaired  over  both  legs,  especially 
the  right,  though  this  is  only  discoverable  on  close  exami- 
nation. He  says  that  contact  of  the  bed-clothes  gives  rise 
to  an  unnatural  sensation  in  the  right  foot.  The  knee-jerks 
are  both  highly  exaggerated,  the  right  more  than  the  left. 
Ankle-clonus  is  present  on  both  sides. 

Examination  of  the  back  shows  a  slight  prominence,  em- 
bracing the  second,  third,  and  fourth  vertebras.  There  is 
no  sensitiveness  on  pressure  over  these  prominences,  and 
no  pain  is  excited  when  the  patient  allows  himself  to  come 
down  hard  on  his  heels.     The  heart  is  in  normal  condition. 


Pain  in  Left  Side  and  Groin,  gradually  increasing^  and  made 
worse  by  Motion.  Gradual  Impairment  of  the  Use  of  the 
Legs,  with  Disturbance  of  Sensibility  and  Exaggerated 
Tendon-Reflexes. 

A  colleague  of  the  writer  was  visited  by  a  lady  who  came 
to  him  suffering  excruciating  pain  in  both  flanks,  but  es- 
pecially in  the  left.  In  fact,  the  pain  at  the  time  of  her 
visit  was  so  severe  that  she  made  her  way  into  his  office 
bent  over  double,  and  almost  on  her  hands  and  knees.  He 
asked  me  to  see  her  a  little  later,  and  the  following  history 
was  obtained :  — 

She  had  been  a  strong,  healthy  woman  until  about  a  year 
previously,  when  she  began  to  have  a  pain  in  the  left  side,  in 


6o 

the  neighborhood  of  the  descending  colon.  This  was  re- 
ferred by  the  physician  whom  she  consulted,  to  a  condition 
of  neurasthenia  and  indigestion,  and  she  was  advised  to  take 
a  trip  into  the  country.  This  she  did,  but  while  away  she 
grew  steadily  worse,  and  fell  gradually  into  the  condition 
described.  At  that  time  there  was  but  little  disturbance  of 
motion  of  the  legs ;  but  this  steadily  increased,  so  that 
within  a  few  months  after  the  first  visit  above  alluded  to 
she  could  not  stand  alone.  The  sensibility  of  the  skin  was 
at  first  much  less  affected  than  the  motion,  but,  little  by 
little,  this  too  became  involved  as  high  as  the  groin,  and 
finally,  though  to  a  less  degree,  as  high  as  the  navel.  The 
back  was  less  involved  than  the  abdomen,  as  regards  sensi- 
bility, at  the  levels  indicated.  The  increase  of  pain  through 
motion  was  first  noticed  a  few  months  after  her  illness  began, 
on  the  occasion  of  stepping  into  a  carriage,  but  it  became 
finally  so  marked  that  even  turning  the  head  to  one  side  or 
gaping  widely  would  precipitate  an  attack  of  pain.  The 
sphincters  were  not  affected  at  first,  but  soon  became  in- 
volved to  a  slight  degree.  The  abdominal  reflex  was 
absent.  The  subsequent  history  of  the  case  will  be  given  in 
the  course  of  the  discussion. 

LI. 

Severe  Pain  around  the  Body,  increased  by  Movement ;  Para^ 
piegia,  of  Gradual  Increase  ;  Death. 

This  patient  was  a  woman,  fifty  years  old,  with  a  record 
of  good  previous  health.  About  the  middle  of  May,  1889, 
she  began  to  be  attacked  with  severe  pain  and  "  dragging 
sensations  "  in  the  right  side.  These  pains  grew  steadily 
worse,  and  were  increased  by  every  motion  or  by  lying  on 
the  left  side.  After  a  week  or  ten  days  the  pain  remitted 
considerably,  though  only  for  a  short  time.  Very  soon  it 
spread  to  the  left  side,  and  eventually  disappeared  wholly 
from  the  right  side.     It  also  involved  the  abdomen  at  the 


no  I 


6i  » 

level  of  the  lower  ribs.  She  gained  some  reHef  by  sitting 
up  in  bed,  propped  by  pillows  and  with  the  chin  resting  on 
the  chest.  Any  attempt  to  held  the  head  erect  or  to  take  a 
more  recumbent  position  greatly  increased  her  suffering. 
Solid  food  caused  nausea. 

Up  to  August  4  there  was  no  loss  of  power  in  the  legs, 
but  the  next  day  this  came  on,  and  rapidly  increased.  On 
the  whole,  the  pain  grew  worse,  but  occasionally  it  would 
remit,  even  completely.  A  sense  of  numbness  was  felt  in 
the  lower  part  of  the  body  below  the  thighs. 

By  August  29  she  was  unable  to  walk,  though  move- 
ments of  the  legs  in  bed  were  still  possible.  The  abdomen 
had  become  distended  with  gas,  and  peristalsis  was  dimin- 
ished.    The  knee-jerks  were  found  diminished. 

An  electrical  examination,  made  August  23,  showed  a 
marked  diminution  of  reaction  to  the  faradic  current,  of 
all  the  muscles  of  the  legs  and  thighs,  and  sv  ■'■  contrac- 
tions as  occurred  were  slow  and  feeble.  The  abdominal 
muscles  did  not  react  at  all.  Marked  impairment  of  sensi- 
bility in  all  forms  was  present  over  both  legs  and  over  the 
abdomen.  Even  deep  pin-pricks  were  generally  not  felt  in 
the  legs.  The  ansesthesia  of  the  abdomen  was  less  com- 
plete, but  mounted  higher  on  the  left  side  than  on  the  right, 
extending  there  to  about  the  ninth  rib.  The  epigastric  reflex 
was  preserved  on  the  right  side,  but  lost  on  the  left. 

The  patient  subsequently  failed  steadil}^,  and  died  in 
about  a  month,  deep  bed-sores  having  formed  on  the  sacrum 
and  the  heels. 

The  record  of  the  post-mortem  examination  will  be  given 
in  connection  with  the  discussion  of  the  case. 


62 


LII. 


Spasm  of  Muscles  about  the  Hip  following  Injury.     Hemi- 

anesthesia. 

A  middle-aged  woman  of  no  great  intelligence  suffered  a 
fall  of  moderate  intensity,  but  was  able  to  walk  home, 
though  in  a  highly  nervous  state,  which  persisted  contin- 
uously. Her  left  leg,  which  had  been  slightly  injured  about 
the  hip,  became  very  painful,  the  pain  being  increased  by 
the  slightest  passive  movement.  The  muscles  about  the 
thigh  and  pelvis  were  constantly  contracted,  as  if  to  prevent 
motion  at  the  hip  joint,  and, 'as  a  result,  the  pelvis  was 
strongly  tilted  upward  on  the  left  side,  the  neighborhood  of 
the  left  hip  joint  becoming  very  prominent.  The  skin  over 
the  left  leg,  and  to  a  less  degree  over  the  whole  left  side, 
including  the  arm,  trunk  (left  half),  and  face,  became  more 
or  less  anaesthetic,  except  about  the  hip,  where  it  was  hyper- 
aesthetic.  As  the  case  progressed  the  patient  became  able 
to  get  about  on  crutches,  but  dragged  the  left  leg,  not  mov- 
ing it  even  at  the  hip  joint.  Medico-legal  complications 
were  present.  Eventually  she  recovered,  but  not  until  after 
several  years. 

LIII. 

Pain   along  the  Course  of  the  Sciatic  Nerve^  associated  with 
Scoliosis  a  fid  Muscular  Spasm. 

A  sailor,  thirty-eight  years  old,  awoke  one  morning,  after 
a  hard  day's  work  of  lifting  heavy  freight,  with  a  severe  pain 
in  the  small  of  the  back.  This  pain  persisted  four  days, 
and  then  left  the  back,  and  made  its  appearance  in  the  back 
of  the  right  thigh,  and  extended  down  through  the  calf  and 
into  the  foot. 

While  lying  in  bed,  he  was  perfectly  comfortable ;  but  any 
attempt  to  sit  up  or  walk  brought  on  a  "tearing"  pain. 
There  was  a  constant  sense  of  tingling  along  the  course  of 
the  sciatic  nerve,  and  pressure  over  the  sciatic  notch  caused 
the  same  pain  as  is  experienced  in  walking. 


Case  LIU. 


63 

The  patient  is  a  heavy,  well-nourished  man.  He  stands 
with  a  marked  lateral  curvature  of  the  spine  (see  illustra- 
tion), which  is  maintained  by  muscular  spasm.  Walking  is 
associated  with  a  pronounced  limp  of  the  right  leg.  There 
is  an  ill-defined  swelling  extending  down  the  thigh  from  the 
right  iliac  crest,  but  palpation  shows  no  change  in  the  con- 
sistency of  the  tissues  of  this  area  from  that  of  the  sur- 
rounding muscle.  The  spine  is  perfectly  flexible  on  bend- 
ing forward.  This  condition  persisted  for  four  months  un- 
relieved, though  several  courses  of  treatment  were  tried. 
Christian  Science  was  finally  resorted  to,  and  resulted  in  a 
cure. 

LIV. 

Paralysis  of  Sphiiicters^  with  Impairment  of  Sensibility  in  the 
"  Saddle  Back  "  Areas  of  the  Thighs. 

A  young  lady,  in  a  fit  of  mania,  leaped  out  of  a  window 
on  the  second  story  of  a  city  house  into  the  yard  below. 
Her  fall  was  somewhat  broken  by  clothes-lines,  but  she  came 
down  with  such  force  as  to  seriously  injure  both  ankles  and 
to  bruise  the  backs  of  the  thighs  and  the  buttocks  on  both 
sides.  She  was  stunned  for  a  moment,  but  quickly  re- 
covered consciousness,  and  screamed  with  pain  and  excite- 
ment when  handled.  It  is  uncertain  how  far  she  was  dis- 
abled in  the  beginning,  but  the  arms  were  apparently  all 
right  from  the  first,  while  the  legs,  although  not  wholly 
paralyzed,  were  greatly  weakened.  She  was  also  unable  to 
raise  herself  into  a  sitting  position,  in  spite  of  violent  efforts. 

At  first  there  was  retention  of  urine,  but  this  quickly  gave 
way  to  a  paralytic  dribbling,  and  it  was  found  that  the  ves- 
ical and  rectal  sphincters  were  both  completely  paralyzed. 
On  this  account  the  catheter  had  to  be  used  from  the  first, 
and  her  distress  was  augmented  by  the  fact  that  a  severe 
acute  cystitis  very  quickly  developed. 

She  lay  in  bed  three  months,  and  during  that  time  the 
muscles  of  the  trunk  and  legs  improved  gradually  in  strength, 


64 

SO  that  at  the  last  she  was  able  to  walk  across  the  room  and 
out  of  the  house  with  but  little  help.  From  that  time  to  the 
present,  a  period  of  nearly  two  years,  she  has  been  slowly, 
but  steadily  gaining ;  and  now  the  legs  may  be  considered  as 
having  normal  strength.  The  knee-jerks  are  absent,  as  they 
presumably  were  from  the  beginning.  There  is  still  partial 
paralysis  of  the  sphincters  of  the  bladder  and  rectum,  so  that 
the  urine  passes  whenever  she  is  making  any  strong  effort, 
as  in  cHmbing,  sneezing,  or  laughing,  and  the  contents  of 
the  rectum  escape  whenever  they  are  at  all  loose. 

Examination  shows  that  the  anal  sphincter  is  in  a  state  of 
partial  contraction,  but  gives  way  at  the  slightest  pressure  of 
the  finger,  and  can  easily  be  dilated  widely.  There  is  im- 
pairment of  sensibility,  in  all  its  modes,  over  the  so-called 
"saddle  back"  area, —  that  is,  the  buttocks,  the  posterior 
surfaces  of  the  thighs  almost  to  the  popliteal  space,  and  the 
perinaeum  and  vulva.  On  the  right  side  this  impairment  is 
much  greater  than  on  the  left,  so  that  a  sharp  and  deep 
prick  or  an  electric  spark  is  scarcely  felt  at  all,  and  not  felt 
as  pain. 

The  anal  sphincter  does  not  respond  to  even  the  strongest 
faradic  currents,  but  does  contract  with  a  moderately 
quick  motion  under  galvanic  excitation,  the  effect  of  the 
negative  and  positive  pole  being  nearly  equal. 

It  should  be  said  that  from  the  first  the  patient  has  been 
aware  that  the  passage  of  the  faeces  did  not  give  rise  to  the 
normal  sensation,  and  has  also  recognized  the  loss  of  sensi- 
bility of  the  skin.  When  a  strong  voluntary  effort  is  made, 
the  sphincter  ani  can,  by  the  finger  of  the  examiner,  be  felt 
to  contract  slightly. 

In  other  respects  the  patient  is  now  in  perfect  health. 


65 


LV. 

Pai7i  in  the  Left  Leg  a?id  Foot,  following,  in  general,  the 
Course  of  the  Sciatic  Nerve ;  later,  Parcesthesia  and  Loss 
of  Power. 

This  patient  was  a  gentleman  of  seventy,  of  fine  health 
and  strong  character.  The  symptom  that  first  troubled 
him  was  pain  in  the  middle  toe  of  the  left  foot,  coming  and 
going,  and  suggesting  an  antecedent  sprain  or  hurt.  For  six 
months  nothing  else  followed,  and  even  this  pain  was  not 
constant.  At  the  end  of  six  months  the  pain  attacked  him 
in  the  lower  back,  and  ran  down  the  posterior  and  outer 
portion  of  the  left  thigh  and  leg  and  into  the  outer  half  of 
the  foot.  When  he  walked,  this  portion  of  the  sole  felt  as  if 
he  was  stepping  on  small  marbles.  For  a  time  the  pain  was 
so  severe  that  he  had  to  take  laudanum  daily.  Then  he  was 
sent  to  Florida  for  change  of  air,  and  here  he  grew  a  little 
better ;  but  while  the  pain  lessened  somewhat  the  muscles 
grew  weak  and  wasted.  Then  the  right  leg  became  attacked 
in  a  similar  manner,  and  there  also  the  pain  was  mainly  on 
the  posterior  and  outer  surface  of  the  thigh.  After  the  right 
leg  became  involved,  the  pain  in  the  left  leg  became  again 
more  severe,  and  both  grew  so  weak  that  walking  was 
almost  impossible.  The  extensor  quadriceps  cruris  group  of 
muscles  became  especially  weak  and  also  atrophied,  so  that 
going  over  the  stairs  was  out  of  the  question.  Deep  pres- 
sure over  these  muscles  gave  rise  to  pain.  There  was  no 
disorder  of  micturition  or  defecation.  The  knee-jerks  were 
soon  lost. 

It  was  when  the  patient  was  in  this  condition  that  he  was 
first  examined  by  the  writer ;  and  from  then  on  for  six 
months  or  more  he  grew  worse  and  worse,  suffering  agonies 
of  pain,  and  becoming  more  and  more  helpless.  Finally,  he 
died  from  exhaustion.  The  pathological  diagnosis,  as  deter- 
mined clinically  and  confirmed  post-mortem,  will  be  given  in 
the  course  of  the  discussion. 


6/ 

/'<3;/«  2«  the  Back  and  Sciatic  Areas. 

The  patient  was  an  unmarried  lady  of  thirty-five,  with  no 
history  of  neurotic  tendencies  or  nutritional  weakness  of  any 
serious  character.  On  the  contrary,  she  had  had  vigorous 
health,  and  had  worked  very  hard.  As  regards  family  his- 
tory, one  sister  had  had  an  extensive  tuberculosis  of  the 
hip  and  of  the  lung,  rheumatism  had  been  prevalent  in  her 
mother's  family,  and  several  of  her  father's  relatives  had 
suffered  from  deafness.  She  was  a  school-teacher,  and,  be- 
sides working  in  that  way,  she  had  taken  extra  classes  of 
various  sorts,  and  had  had  a  good  deal  of  physical  exercise, 
also  in  the  way  of  teaching. 

In  190 1  she  went  abroad  with  friends,  and  stood  about  to 
a  considerable  extent  in  picture  galleries  and  cathedrals,  and 
was  perhaps  exposed  in  this  way  to  dampness.  In  July  she 
began  to  suffer  from  severe  _pains__ in  the  small  of  the  back, 
called  "  lumbago  "  by  the  local  doctor.  In  a  month's  time 
she  thought  herself  to  be  well  again,  but  after  two  months 
more  the  pain  returned,  and  this  time  it  extended  down  the 
back  of  the  left  thigh  and  leg,  and  even  into  the  left  foot. 
She  also  suffered  from  chilblains  on  her  fingers  and  toes, — 
a  malady  to  which  she  had  been  previously  subject.  There 
was  no  fever,  and  she  struggled  against  her  difficulties  for 
fear  of  putting  her  friends  to  inconvenience.  By  this  time 
the  pain  had  involved  also  the  right^thigh,  following,  in  gen- 
eral, the  course  of  the  sciatic  nerve.  The  patient  could  lie 
only  on  her  back,  and  there  was  tenderness  over  the  lower 
lumbar  vertebrae.  For  a  few  days  there  was  some  difficulty 
in  passing  uriae,  and  a  skilful  physician  considered  that  she 
had  slight  degree  of  myelitis.  Her  appetite  was  poor  and 
her  food  was  not  well  digested.  She  had  gas  in  the  stomach  y 
and  bowels,  some  degree  of  constipation,  and  a  sense  of 
weight  in  the  abdomen  ;  but  she  thought  little  of  this,  because 
she  frequently    h\d    similar  symptoms  when  unable  to  get 


68 

sufficient  exercise.  Massage  and  actual  cautery  failed  to 
relieve  the  sciatic  pain,  but  after  some  months  of  rest  in  bed 
the  patient  improved  somewhat  and  returned  home,  though 
under  the  care  of  a  nurse. 

Here  a  careful  examination  was  made,  with  the  following 
result :  The  thoracic  and  abdominal  organs  were  in  good 
condition.  There  was  still  tenderness  over  the  lower  lumbar 
region  and  at  certain  points  along  the  course  of  the^ciatic 
nerv'-e.  There  was  no  paralysis  or  disturbance  of  sensibility 
of  the  skjji.  The  muscles  did  not  show  atrophy  more  than 
one  would  expect  from  disuse.  She  could  lie  only  on  her 
back,  because  if  she  turned  to  either  side  the  pain  was 
brought  on.  It  was  possible  to  walk  slowly  for  a  few 
minutes  but  very  difficult  to  go  upsjtairs,  although  there  was 
no  real  paralysis  anywhere.  The  knee-jerks  were  slight. 
The  flexibility  of  the  spine  was  poor,  the  back  moving  all 
in  one  piece.  She  has  been  treated  by  rest  in  bed  and  hot 
fomentations  to  the  back ;  and  under  this  she  has  slowly  but 
steadily  improved  in  all  respects. 

LVIII. 

Pain  about  the  Waist  and  in  the  Back ;   Great  Nervous 

Excitability. 

This  patient  was  a  country  physician  of  large  practice,  who 
consulted  one  of  the  writers  for  a  severe  pain  in  the  back 
and  flanks,  which  he  had  already  had  at  that  time  for  about 
four  months.  When  he  was  examined  he  was  in  such  a 
highly  nervous  state  that  it  was  very  difficult  to  estimate  the 
severity  of  his  pain.  He  had  also  been  taking  more  or  less 
morphine  and  other  drugs  to  keep  himself  going;  and, 
although  by  their  aid  he  had  worked  until  within  a  month 
of  the  consultation,  yet  it  was  at  the  expense  of  his  nervous 
strength,  so  that  at  the  time  of  the  examination  he  was  in 
a  thoroughly  hysterical,  broken-down  condition.  The  diffi- 
culty of  estimating  the  significance  of  his  pain  was,  more- 


>^ 


69 

over,  increased  by  the  fact  that  for  some  years  past  he  had 
been  subject  to  what  he  had  considered  as  lumbago,  coming 
on  in  attacks. 

This  present  pain  was  felt  at  first  at  the  level  of  the  lower 
ribs,  where  it  encircled  his  body  Hke  a  belt.  At  times  it  had 
been  so  severe,  he  said,  that  he  had  not  been  able  to  sleep 
or  to  sit  still  in  any  one  position.  His  appetite  had  been 
greatly  impaired,  and  he  had  lost  thirty-one  pounds  in  five 
months.      Nevertheless,  he  did  not  look  greatly  exhausted. 

He  gave  the  further  history  that  fourteen  years  before  he 
was  thrown  from  a  carriage,  and  had  for  two  days  a  partial 
loss  of  power  and  sensibility  in  his  legs.  He  had  also  had 
a  good  deal  of  mental  worry  on  account  of  his  financial 
affairs.     Two  brothers  and  a  sister  had  died  of  tuberculosis. 

The  physical  examination  was  made  with  special  reference 
to  the  condition  of  the  sensibility,  and  of  the  flexibility  of 
the  spine ;  but  the  result  of  the  investigation  was  not  alto- 
gether satisfactory,  and  no  positive  disturbance  of  sensibility 
could  be  made.  He  was  so  excited  and  nervous  that  his 
testimony  was  not  quite  reliable. 

As  regards  the  flexibility  of  the  spine,  it  was  noticeable 
that  he  moved  guardedly,  but  could  bend  forward  fairly  well. 
On  the  other  hand,  the  sidewise  bending  was  much  re- 
stricted ;  and  it  was  less  good  toward  one  side  than  it  was 
toward  the  other. 

He  was  advised  to  see  an  orthopedic  surgeon,  who  ad- 
vised the  use  of  a  plaster  jacket ;  but  he,  too,  found  the 
patient  very  nervous,  and  was  inclined  to  attribute  at  least  a 
portion  of  his  symptoms  to  that  cause  and  to  his  habit  of 
taking  anodynes  for  the  relief  of  the  pain,  though  as  a  matter 
of  fact  the  actual  quantity  of  morphine  taken  had  not  been 
very  large. 

The  further  course  of  the  case  will  be  given  in  connection 
with  the  discussion. 


70 


LIX. 

Fain,  followed  by  Atrophy  and  hnpairment  of  Sensibility,  in 
the  Areas  of  Distribution  of  Both  Anterior  Crural  Nerves. 

This  patient,  a  stout,  vigorous  man  of  seventy,  began  to 
suffer  from  pain,  mainly  referred  to  the  anterior  surface  of 
his  thighs,  in  February,  1902.  Sometimes  this  pain  would 
spread  somewhat  beyond  the  area  mentioned  and  involve 
the  inner  side  of  the  right  leg,  below  the  knee,  or  the  lateral 
aspect  of  the  thigh. 

The  character  of  the  pain  varied  from  an  intense  sense 
of  ''drawing,"  "  as  if  his  nerves  were  too  short,"  to  a  severe 
boring,  usually  referred  to  the  knee  and  making  the  im- 
pression of  augers  being  driven  with  force  into  the  joint. 
Lying  on  the  back  increased  the  pain,  so  that  for  several 
months  he  had  spent  most  of  the  night  in  his  chair.  The 
quadriceps  extensor  cruris  muscles  have  been  growing  weak, 
especially  those  of  the  left  leg,  so  that,  in  fact,  he  cannot 
extend  the  left  leg  at  the  knee.  The  knee-jerks  have  dis- 
appeared. The  sensibility  of  the  skin  has  been  diminished 
over  portions  of  the  painful  areas,  and  this  change  is  most 
marked  on  the  right  side,  although  it  is  the  left  leg  which 
is  the  weaker  of  the  two.  There  are  certain  areas,  a  few 
inches  in  diameter,  within  which  the  sensibility  to  the  prick 
of  a  needle  is  almost  wholly  wanting.  One  such  area  is  just 
above  the  knee,  another  is  over  the  lower  part  of  the  skin. 
No  other  muscles  or  nerve-areas  are  involved  except  those 
related  to  the  distribution  of  the  anterior  crural  nerve. 

Neither  deep  palpation  of  the  abdomen  nor  digital  exami- 
nation of  the  rectum  reveal  any  certain  indications  of 
disease.  The  spine  is  not  sensitive  to  heavy  percussion, 
but  is  perhaps  less  flexible  than  it  should  be  when  he  bends 
forward  and  back.  There  is  a  systoHc  murmur  at  the  apex 
of  the  heart,  but  no  irregularity  nor  considerable  enlargement. 
The  urine  is  normal. 


71 


LX. 


Tendency  to  the  Occurrence  of  Severe  Hypercesthesia  of  the  An- 
terior Surface  of  Left  Thigh,  making  Locomotion  Painful 
and  Difficult. 

The  patient  is  a  scientific  man,  sixty-six  years  old.  His 
symptoms  first  showed  themselves  nearly  twenty  years  ago, 
after  an  over-exertion  in  climbing  in  the  Alps, —  an  exercise 
to  which  he  was  much  addicted,  and  which  he  had  previously 
practised  without  harm.  During  the  whole  of  this  long 
period  the  symptoms  have  remained  about  the  same,  al- 
though at  one  time,  while  on  a  vacation  in  Switzerland,  he 
improved  so  much  that  after  a  while  he  could  walk  half  a 
mile  without  crutches,  and  from  time  to  time  temporary  im- 
provement has  occurred,  especially  when  he  has  been  in 
high  places.  He  generally  felt  better  in  the  morning,  and 
could  then  walk  fifty  rods  or  so  without  trouble,  although  at 
times  even  this  exertion  would  precipitate  an  attack  of  dis- 
comfort and  disability  of  the  leg.  Ten  years  ago  he  adopted 
the  use  of  crutches  so  as  to  go  about  at  pleasure,  using  only 
the  left  leg ;  and  in  this  way  he  could  walk  long  distances, 
and  even  accomplish  some  mountain  climbing. 

His  principal  discomfort  was  due  to  a  hyperaesthesia  of 
the  skin,  which  was  brought  on  by  those  exertions,  and  this 
was  sometimes  so  great  that  the  friction  of  his  clothing  was 
unbearable.  If  his  silk  bandage,  which  he  wore,  slipped 
from  the  leg,  he  would  feel  himself  utterly  prostrated  from  the 
irritation  produced  by  the  contact  of  his  skin  with  his  under- 
wear. This  irritability  of  the  skin  was  mainly  confined  to 
the  anterior  surface  of  the  thigh,  and  about  a  year  before  I 
saw  him  an  operation  had  been  done,  consisting  of  the  sec- 
tion of  the  cutaneous  nerve  supplying  this  area.  After  this  he 
was  much  better  for  a  time,  but  then  the  trouble  returned, 
and  a  second  operation  was  done.  This  also  brought  some 
improvement,  but  he  relapsed  on  leaving  the  hospital,  and 
attributed  this  to  the  fact  that  he  left  too  soon.     In  the  end 


72 

he  had  a  treatment  of  a  somewhat  different  sort,  in  which 
static  electricity  played  a  part,  and  entirely  recovered. 

The  following  is  an  extract  from  a  letter  recently  re- 
ceived :  — 

July  17,  1902. 

If  last  July  a  fortune-teller  had  said,  "  In  one  year  from 
now  you  will  be  tramping  through  Alpine  snow,  eight  thou- 
sand feet  above  sea  level,"  I  would  have  replied,  "  If  you 
know  your  business,  you  would  get  up  some  more  likely 
story  than  that."  And  yet  this  is  what  I  have  just  come 
from  doing. 

LXI. 

Toe-drop  of  the  Right  Foot,  of  rather  Sudden  Onset. 

A  student  twenty-one  years  old  and  in  good  health  had 
taken  a  pleasure  trip  to  Jamaica.  The  morning  on  which  he 
arrived  at  the  island  he  noticed  that  he  repeatedly  tripped 
over  slight  obstacles,  with  his  right  foot.  This  trouble  in- 
creased for  two  days,  and  then  for  six  weeks  remained  sta- 
tionary. During  this  time  he  was  obliged  to  raise  the  right 
foot  high  in  walking,  to  prevent  the  toe  dragging  on  the 
ground.  There  was  no  pain  and  no  disturbance  in  sensi- 
bility. The  knee-jerks  were  normal.  The  electrical  irrita- 
hility  of  the  right  tibialis  anticus  was  quantitatively  de- 
creased to  faradism  and  increased  to  galvanism,  while  the 
contraction  to  the  latter  was  somewhat  sluggish.  Galvanic 
or  faradic  stimulation  over  the  right  peroneal  nerve  caused 
a  contraction  of  the  peronei,  but  not  of  the  tibialis  anticus. 

There  had  been  no  change  in  the  patient's  habits  except 
that  he  had  helped  scrubbing  down  the  decks  of  the  ship 
the  first  few  days  of  the  voyage.  As  this  had  to  be  done  on 
his  hands  and  knees,  it  had  made  his  knees  rather  sore. 
There  was  no  history  of  fever  or  constitutional  symptoms. 
The  patient  had  never  used  alcohol  or  tobacco. 


73 

LXII. 

Gradual  Loss  of  Power  in  Both  Legs^  causing  Toe-drop. 

The  following  brief  notes  give  the  essential  features  of 
an  interesting  case  which  I  had  the  opportunity  to  observe 
incidentally  for  a  number  of  years,  but  never  examined  in 
detail  professionally. 

The  patient  was  a  healthy,  intelligent  woman,  who  began, 
when  about  thirty-five  years  old,  to  have  a  loss  of  power  in 
the  extensors  of  the  right  foot  and  toes,  without  disturbance 
of  sensibility.  After  a  time  the  extensors  of  the  left  foot  also 
showed  the  same  signs  of  giving  way,  and  little  by  little  the 
disorder  progressed,  until  after  two  or  three  years  it  was 
impossible  for  her  to  bend  the  feet  at  all  at  the  ankle,  and  in 
walking  she  was  obliged  to  lift  the  knee  very  high  in  order 
to  carry  the  toes  clear  of  the  ground.  The  hands  had  not 
been  involved  at  the  end  of  three  years.  The  general  nutri- 
tion remained  good ;  and,  in  fact,  no  other  disorders  were 
complained  of  except  those  above  noted.  The  condition  of 
the  knee-jerks  is  not  positively  known. 

LXIII. 

Wasting  and   Weakness  of  the  Extensor  Muscles  of  the 

Left  Thigh. 

This  patient  was  a  gentleman  of  fifty,  who  was  referred  by 
his  surgeon  on  account  of  the  above-mentioned  condition. 
On  being  questioned,  he  gave  the  following  history :  — 

About  four  months  previously  he  had  felt  a  slight  sore- 
ness on  the  inner  side  of  the  left  knee,  and  this  soon  grew 
so  much  worse  that  he  could  not  walk  without  limping.  At 
the  end  of  a  week  he  consulted  a  physician,  who  said  that 
he  had  "  water  on  the  knee,"  and  advised  free  blistering. 
This  seemed  to  do  much  good,  and  he  had  already  improved 
somewhat  when  he  was  thrown  out  of  a  sleigh  and  wrenched 
the  leg  a  little,  which  again  made  his  knee  worse.     After  a 


74 

time  he  again  improved,  so  that,  ahhough  his  knee  was  still 
weak,  there  was  no  soreness  unless  he  walked  too  far.  Use 
of  the  knee,  however,  brought  on  a  lameness  which  was  felt 
throughout  the  muscles  of  the  thigh. 

On  comparison  of  the  two  legs  it  was  found  that,  while 
the  muscles  below  the  knee  were  nearly  equal  on  the  two 
sides,  those  above  the  knee,  and  especially  the  extensors, 
were  considerably  wasted,  so  much  so  that  there  was  a  dif- 
ference of  three  and  a  half  centimetres  between  the  two 
thighs,  when  measured  at  a  point  twelve  centimetres  above 
the  knee.  There  was  no  resistance  to  passive  motion,  and 
no  sensitiveness  over  the  sciatic  nerve.  Even  the  muscles 
below  the  left  knee  were  somewhat  weaker  than  the  corre- 
sponding muscles  of  the  right  leg,  and  the  whole  left  leg  felt 
cooler  to  the  touch  than  the  right. 

The  faradic  irritability  of  the  extensor  quadriceps  cruris 
group  of  muscles  of  the  left  leg  was  moderately  diminished 
as  compared  with  that  of  the  right  leg.  There  was,  how- 
ever, no  quantitative  difference  between  the  reactions  of  the 
two  sides. 

LXIV. 

Spastic  Equino-varus^  with  Impairment  of  the  Sensibility  of 
Foot  and  Leg;  Sei'ious  Impairment  of  Nutritio7i ;  High 
Degree  of  Nervous  Weakness^  following  Moderate  Injury. 

The  patient  was  a  woman  twenty-seven  years  old,  married, 
hard-working,  and  of  fairly  good  previous  health,  though  of 
no  considerable  education. 

In  March,  1891,  while  dismounting  from  a  train,  she  was 
thrown  down  by  a  sudden  motion  of  the  car,  and  received 
some  slight  strains  and  bruises  and  a  severe  fright.  In  con- 
sequence of  this  she  fell  into  a  state  of  extreme  nervousness 
and  debility.  Her  milk  ceased  to  flow,  so  that  she  was  no 
longer  able  to  nurse  her  child,  and  she  lost  weight  rapidly, 
to  the  amount  of  perhaps  thirty  pounds,  and  became  ex- 
tremely pale.     Her  right  ankle  had  been  somewhat  injured, 


75 

and  was  at  first  bandaged.     Gradually  a  spasmodic  condi- 
tion of  the  muscles  developed,  so  that  the  foot  was  held  per- 
manently in  a  position  of  extreme  equino-varus,  and  became 
blue  and  swollen  from  interference  with  the  circulation,  per- 
haps complicated  by  vaso-motor  disorders.     Occasionally,  the 
spasm  increased,  and  became  painful.     Although  the  foot 
could  not  be  voluntarily  replaced,  it  was  evident  on  careful 
examination  that  the  muscles  antagonistic  to  those  in  spasm 
were  not  really  paralyzed.     It  was  also  found  that  the  ham- 
string muscles  of  the  same  leg  and  all  the  muscles  about 
the  hip  joint  were  in  contraction.     Handling  the  foot  and  leg 
gave  rise  to  pain,  but  tests  showed  a  marked  diminution  of 
the  sense  of  contact,  and  of  pain  (as  tested  by  pricking  with 
a  pin) ;  and  this  was  true  not  only  of  the  foot  and  leg,  but  of 
the  whole  right  half  of  the  body  and  face.     It  was  noticed 
that  flies  were  allowed  to  crawl  over  the  affected  foot  and  leg 
as  if  their  presence  was  not  recognized,  while  they  were  at 
once  brushed  off  if  they  aUghted  on  the  other  side.     The 
field  of  vision  of  the  right  eye  was  somewhat  diminished  in 
size  for  motion  and  for  white  test-objects,  and  the  acuity  of 
vision  of  the  right  eye  was  also  found  to  be  less  than  of  the 
left.     The  hearing  of    the  right  ear  was  slightly  less  than 
that  of  the  left. 

The  case  was  one  where  suit  for  damages  had  been 
brought;  but  the  conditions  described  persisted  for  many 
years  after  the  case  was  settled,  and  in  fact  have  continued 
in  some  degree  up  to  the  present  time  (1900). 

LXV. 

Double  Vision,  Neuralgic  Pains  in  Legs,  Numbness  of  Hands, 
Impairment  of  Speech. 

An  acrobat,  thirty-eight  years  old,  had  been  travelling 
with  a  circus  for  ten  years,  during  which  time  he  constantly 
used  alcohol  to  excess.  He  contracted  syphilis  when  he 
was  thirty,  but  when  the  secondary  symptoms  appeared  he 


76 

began  treatment,  which  he  continued  several  months,  and 
since  then  has  not  been  troubled  in  that  way.  He  has 
been  married  several  years,  but  has  no  children. 

Five  months  ago,  while  going  through  his  usual  high 
trapeze  performance,  he  had  a  sudden  attack  of  double 
vision  come  over  him  just  as  he  launched  himself  into  the 
air  to  catch  a  trapeze  swinging  toward  him.  Unfortunately, 
he  grasped  at  the  wrong  image,  and  fell  forty  feet,  landing, 
by  good  chance,  in  the  net. 

He  suffered  no  injury  from  the  fall ;  but  about  one  week 
ago  he  began  to  have  "  excruciating  pains  "  in  both  legs, 
which  he  likened  to  hot  needles  being  thrust  quickly  in  and 
out. 

He  has  kept  at  his  work  up  to  the  present  time,  though 
he  was  obliged  to  give  up  high  performances  on  account 
of  his  diplopia,  which  seems  to  be  due  to  a  left  internal 
strabismus.  The  urine  is  normal,  and  the  bladder  functions 
undisturbed.  The  sexual  desire  has  been  increased  for  the 
past  few  weeks.  Examination  shows  paresis  of  the  external 
rectus  of  the  left  eye.  The  pupils  are  regular,  and  the  right 
reacts  normally,  while  the  left  responds  only  slightly  to  light ; 
but  reaction  with  accommodation  is  normal.  The  right  knee- 
jerk  is  normal,  but  the  left  is  exaggerated.  The  gait  is  un- 
affected. The  above  record  carries  the  history  to  the  time 
of  the  first  examination. 

The  patient  was  next  seen  four  years  later.  He  says  he 
does  not  feel  as  strong  as  formerly.  He  has  been  much 
troubled  by  shooting  pains  in  his  back  and  legs,  recurring 
by  spells.  Double  vision,  when  looking  toward  the  left,  has 
been  persistent.  There  has  been  a  sense  of  numbness  in 
the  fingers  of  both  hands  for  a  year  or  more. 

The  urine  escapes  involuntarily  once  in  a  while,  and  there 
is  complete  loss  of  sexual  power.  Physical  examination  of 
the  eyes  shows  the  san^e  condition  as  formerly ;  but  the  right 
knee-jerk  is  absent,  while  the  left  still  remains  exaggerated. 
There  is  now  a  well-marked  coarse  tremor  of  the  lips  and 


tongue,  and  the  patient  notices  an  impediment  in  his  speech, 
which  at  times  is  apparent  also  to  others. 

*     LXVI. 

Deep-seated^  Distressing   Pain    in   the   Left  Flank^  increased 
by  Motion ;  Depression  and  Debility, 

This  patient  was  a  married  man  of  forty-four,  Hebrew  by- 
race,  and  an  anxious,  nervous  man  by  temperament.  He 
was  a  picture  of  misery  when  he  was  first  examined,  which 
was  in  the  summer  of  1897.  He  had  then  thought  it  neces- 
sary to  confine  himself  to  the  house  and  often  to  bed, 
because  of  the  pain  and  distressing  sensations  above  noted, 
though  in  fact  there  was  no  reason  that  he  should  not  have 
gone  out,  and  with  a  little  urging,  he  did  so.  He  complained 
that  he  felt  weak  and  miserable,  and  suffered  from  a  sensa- 
tion as  of  a  heavy  ball  rolling  to  and  fro  within  the  left  half 
of  the  abdomen  and  through  to  the  back  whenever  he  at- 
tempted to  walk.  On  further  inquir}^,  he  said  he  had  had 
sharp  thrusts  of  pain,  which  would  run  down  the  arms  into  the 
fingers.  He  did  not  have  them  in  the  legs,  but  the  legs 
used  to  get  "numb,"  so  that  it  was  with  an  effort  that  he 
used  them.  He  also  said  it  was  with  some  difficulty  that  he 
kept  himself  from  stumbling  when  in  the  dark,  and  he 
thought  that  his  micturition  was  a  little  delayed.  It  ap- 
peared that  he  had  had  gonorrhoea  twice,  though  as  a  very 
young  man.  He  had  never  had  a  "  sore  "  to  his  knowledge ; 
but  in  the  summer  of  1892  large  ulcerations  appeared  on  the 
legs,  and  the  scars  of  these  still  remained  in  the  form  of 
large,  brownish,  depressed  spots.  They  healed  very  slowly, 
he  said,  and  he  thought  his  strength  had  never  been  so 
good  since  then.  At  the  time  that  this  pain  in  the  abdomen 
first  came  on  he  went  to  Rangeley  Lakes ;  but  the  weather 
was  poor,  and  he  came  home  in  a  miserable  condition.  He 
said  he  had  become  impotent,  and  felt  generally  hopeless. 

On  examination  he  was  found  to  sway  somewhat  when  his 


78 

eyes  were  closed,  but  with  an  effort  this  tendency  was  over- 
come. The  right  pupil  was  larger  than  the  left,  but  in  the 
centre  of  the  left  cornea  there  was  a  scar  which  he  had  had 
since  boyhood.  The  right  .pupil  r-eacted  normally  to  light, 
the  left  very  slightly.     The  knee-jerks  were  rather  lively. 

This  patient  remained  under  observation  for  many  years. 
At  times  he  could  be  induced  to  go  out,  and  to  engage  ac- 
tively in  business,  but  occasionally  he  would  fall  into  a  con- 
dition of  despondency  over  his  symptoms,  and  would  then 
He  in  bed  for  a  few  days.  The  sensation  of  a  heavy  weight 
in  the  left  flank  remained  constant.  So  long  as  he  stood  still, 
he  was  not  troubled ;  but  the  moment  he  began  to  walk  it 
depressed  him  terribly.  The  legs  felt  stiff,  and,  as  he  said, 
"  numb,"  though  there  was  no  actual  loss  of  sensibility.  The 
shooting  pains  in  the  arm  returned  from  time  to  time,  but  it 
was  difficult  to  make  out  what  they  signified.  At  one  time 
he  was  examined  by  an  eminent  neurologist,  and  pronounced 
to  have  tabes  in  an  incipient  form. 

Treatments  of  every  kind  were  thoroughly  carried  out, — 
counter-irritation,  electricity  in  every  form,  baths  of  various 
sorts,  then  lumbar  puncture ;  but  nothing  brought  permanent 
relief.  His  present  condition  is  not  materially  different 
from  what  it  was  five  years  ago. 

LXVII. 

Severe  Fits  of  Coughing  and  Chokiiig^  Attacks  of  Vomitings 
Pains  of  Inte?ise  Severity,  a?id  Other  Symptoms. 

A  laborer,  forty-three  years  of  age,  had  been  subject  for 
two  months  to  paroxysms  of  coughing  which  were  so  severe 
that  he  would  turn  blue  all  over;  and  sometimes  his  wife 
would  really  think  he  was  dying.  Each  attack  lasted  three 
or  four  minutes,  and  he  had  at  least  one  every  day.  There 
was  no  actual  pain  associated  with  these  spells.  At  times 
he  raised  a  small  quantity  of  thick  mucus. 

At  about  the  time  that  this  trouble  began  he  had  noticed 


79 

a  slight  drooping  of  his  right  eyelid,  and  this  had  grown 
progressively  worse.  There  had  also  been  more  or  less 
pain  in  the  back,  varying  in  character  from  a  dull  ache  to 
sharp  shooting  twinges.  He  had  had  one  or  two  attacks  of 
^'  indigestion  "  during  the  same  period,  associated  with  ab- 
dominal pain  and  vomiting.  The  bowels  moved  pretty  regu- 
larly ;  occasionally,  however,  when  he  felt  an  inclination  to 
have  a  movement,  he  would  find  this  impossible,  but  would 
break  out  in  a  cold  sweat  from  a  severe  pain  in  the  rectum, 
which  would  last  ten  or  fifteen  minutes.  There  was  no 
disorder  of  micturition,  except  some  delay  in  starting  the 
urine. 

Numbness  of  the  fingers  of  the  right  hand  and  of  the 
great  toe  of  the  right  foot  had  also  been  a  source  of  some 
annoyance.  During  the  two  weeks  previous  to  the  time  he 
was  first  seen  the  patient  had  been  unable  to  work,  both  on 
account  of  the  pains  and  because  of  feeling  generally  played 
out. 

The  physical  examination  showed  ptosis,  and  paresis  of 
the  superior,  inferior,  and  internal  rectus  of  the  right  eye. 
The  right  pupil  was  slightly  larger  than  the  left,  but  both 
reacted  normally  to  light.  There  was  hoarseness  of  the 
voice,  and  moderate  exertion  caused  difficulty  and  noisy 
inspiration,  suggesting  laryngeal  obstruction.  By  the  laryn- 
goscope it  was  seen  that  both  vocal  cords  lay  in  the  median 
line,  the  right  being  capable  of  only  slight  motion,  while  the 
left  was  wholly  paralyzed.  There  was  diminished  sensibil- 
ity to  touch  and  pin-prick  over  the  terminal  phalanges  of 
the  right  hand  and  foot.  The  knee-jerks  were  absent.  The 
patient  had  contracted  gonorrhoea  twelve  years  previously, 
and  had  used  alcohol  to  excess  until  three  years  before  the 
present  illness.  There  was  no  positive  evidence  of  his  hav- 
ing had  syphilis. 


8o 

LXVIII. 

Paroxysmal  Attacks  of  Epigastric  Pain. 

A  man  forty- five  years  old  had  been  subject,  for  three 
weeks,  to  paroxysms  of  severe  pain  in  the  epigastrium,  which 
would  come  on  suddenly  in  the  morning  and  last  four  or  five 
hours.  These  attacks  were  associated  with  vomiting.  The 
patient  says  that  at  first  they  came  almost  regularly  every 
other  morning.  He  had  never  had  any  stomach  trouble  be- 
fore, and  can  eat  any  kind  of  food  between  the  paroxysms 
without  distress. 

When  seen  during  an  attack,  the  patient  was  walking 
about  the  room  pressing  both  hands  over  the  epigastrium, 
and  the  tears  were  rolling  down  his  cheeks.  There  was  no 
local  tenderness,  but,  on  the  contrary,  firm  pressure  seemed 
to  give  him  some  relief.  The  pupils  were  equal,  and  re- 
acted normally  to  light  and  with  accommodation.  The 
tongue  was  clean.  The  heart  and  lungs  were  negative.  The 
liver  and  spleen  seemed  normal  in  size.  Palpation  and  per- 
cussion of  the  abdomen  showed  nothing  abnormal.  The 
patellar  and  plantar  reflexes  were  normal. 

During  the  second  and  third  weeks  these  paroxysms  of 
pain  returned  at  irregular  intervals,  sometimes  recurring  two 
or  three  days  in  succession,  sometimes  at  intervals  of  two 
or  three  days.  They  always  came  on  in  the  early  morning, 
and  were  accompanied  by  retching  and  vomiting  of  bile» 
They  were  not  associated  with  any  rise  in  temperature. 
Morphia  was  required  for  relief,  and  when  on  two  occa- 
sions subcutaneous  injections  of  water  were  substituted,  they 
were  without  effect. 

Examination  of  the  gastric  contents  between  the  attacks 
showed  nothing  abnormal,  and  the  inflated  stomach  was 
found  to  be  normal  in  size  and  position. 

Repeated  and  careful  searches  for  plasmodia  in  the  blood 
were  unsuccessful. 

Examination  of  the  urine  showed  neither  albumen,  sugar, 


8I 

nor  lead  to  be  present.  In  spite  of  the  fact  that  no  Plas- 
modia were  found  in  the  blood,  large  doses  of  quinine  were 
given,  and  this  treatment  was  followed  by  a  cessation  of  the 
attacks  for  several  weeks.  Later  reports  from  the  patient, 
however,  stated  that  the  pain  had  returned  as  before,  and 
was  unaffected  by  quinine. 

This  patient  had  had  no  infectious  disease  since  child- 
hood, except  gonorrhoea,  which  he  contracted  fifteen  years 
ago.  He  had  been  in  the  habit  of  using  alcohol  to  excess 
in  his  daily  life,  though  but  rarely  to  the  extent  of  intoxica- 
tion. 

LXIX. 

Atrophy  and  Fam  in  Hands   and  Ar7ns ;    Very  Slow   Pro- 
gression ;  Death  from  Intercurre?it  Disease. 

On  Dec.  28,  1897,  I  was  consulted  by  a  lady  of  twenty- 
seven,  a  person  of  intelligence  and  courage,  on  account  of 
loss  of  power  of  right  hand,  especially  in  the  index  and 
middle  fingers  and  the  thumb,  and  of  pain  in  the  hand  and 
arm.  This  loss  of  power  had  been  noticed  for  a  year  and 
a  half,  the  pain  for  a  somewhat  less  time.  The  pain  seemed 
to  centre  at  a  spot  on  the  back  of  the  forearm  toward  the 
lower  end,  and  spread  thence  through  the  whole  hand.  It 
was  of  "scalding  character."  She  had  also  noticed  that  her 
power  of  distinguishing  heat  from  cold  had  greatly  dimin- 
ished, as  regards  the  right  hand. 

On  examination,  atrophy  of  the  thenar  muscles  of  the 
right  hand  was  found,  and  the  fingers  were  twitched  fre- 
quently by  slight  muscular  contractions,  rather  more  exten- 
sive than  those  usually  described  as  "fibrillary  twitching." 
There  was  almost  complete  loss  of  the  sense  of  pain  to 
the  prick  of  a  pin,  as  well  as  to  changes  of  temperature, 
over  the  hand  and  lower  part  of  the  forearm,  especially  on 
the  extensor  surface.  The  sense  of  touch  was  almost  per- 
fect over  these  same  areas.  Both  knee-jerks  were  markedly 
increased.  A  soft  systolic  murmur  was  heard  at  the  apex  of 
the  heart. 


82 

As  the  disease  progressed,  the  weakness,  atrophy,  and 
fibrillary  twitching  involved  the  left  hand  and  arm  and  the 
muscles  of  the  shoulder  and  upper  part  of  the  back.  The 
impairment  of  sensibility  also  spread,  and  finally  involved 
the  back  of  the  head  and  parts  of  the  face.  After  about  a 
year  she  developed  a  malignant  endocarditis,  characterized 
by  persistent  fever  and  hemorrhages  in  the  retinae  and  the 
skin ;  and  after  another  year  of  illness  she  died.  No 
autopsy  was  allowed. 

LXX. 

Staggering  Gait,  Nystagmus,  Hesitating  Speech,  Clubbed  Foot, 

This  patient  was  a  boy,  eleven  years  old,  with  a  good  family 
history,  none  of  the  relatives  having  suffered  from  any 
serious  disease.  At  the  age  of  six  he  fell  downstairs,  strik- 
ing his  occiput  and  receiving  a  wound  which  left  a  scar  about 
the  size  of  a  quarter  of  a  dollar.  There  were  no  serious 
symptoms  immediately,  but  almost  a  month  later  his  mother 
noticed  that  he  staggered  in  his  walking.  This  symptom 
grew  progressively  worse,  so  that  for  two  years  previous  to 
his  visit  to  Boston  he  had  experienced  considerable  difficulty 
in  getting  about  and  not  infrequently  fell  down,  sometimes 
bruising  himself  severely.  In  fact,  he  was  liable  to  fall  when- 
ever he  tried  to  stand  still  without  support.  During  the 
past  few  months  his  mother  had  noticed  a  peculiar  hesitation 
in  his  speech.  The  bowels  were  constipated,  but  there  was 
no  disturbance  of  the  bladder  function. 

Physical  examination  showed  a  well-developed  and  well- 
nourished  boy.  The  pupils  were  equal  and  reacted  normally, 
but  the  eyes  made  coarse  jerky  movements  when  he  looked 
to  the  extreme  right  or  left.  There  was  also  a  coarse 
irregular  tremor  of  the  head  when  the  attention  was  fixed. 
The  movements  of  the  arms  showed  marked  inco-ordination ; 
and,  when  the  patient  tried  to  grasp  an  object,  the  hand  would 
approach  it  in  a  hovering  manner,  and  then  suddenly  pounce 
upon  it.     The  speech  was  interrupted  and  jerky.     The  gait 


^3 

was  very  unsteady,  and  suggested  marked  tabetic  ataxia  com- 
bined with  the  reeling  seen  in  cerebellar  inco-ordination. 
There  was  no  objective  nor  subjective  disturbance  of  sensi- 
bility. The  spine  was  straight.  The  knee-jerks  were  absent, 
but  the  plantar  reflexes  present.  A  peculiar  deformity  of 
both  feet  was  present,  suggesting  clubbed  foot. 

LXXI. 

Recurrent  Attacks  of  Vomitijig. 

This  patient  is  a  married  man,  of  forty-one,  who  came  into 
the  hospital  April  5,  1902.  By  occupation  he  is  a  driver  for 
Jordan  &  Marsh.  His  complaint  is  of  attacks  of  vomiting, 
protracted  and  recurrent,  which  come  on  without  apparent 
cause,  unless  it  be  nervous  fatigue  or  some  slight  error  in 
diet. 

The  first  of  these  attacks  occurred  a  year  ago,  and  was  pre- 
ceded by  a  series  of  sharp,  darting  pains  in  various  parts 
of  the  trunk.  In  character  these  pains  were  like  those  from 
pricking  with  a  needle.  In  the  following  month  another 
attack  occurred,  which  lasted  five  weeks,  this  time  unattended 
by  pain.  For  the  first  two  weeks  he  vomited  every  ten  or 
fifteen  minutes,  and  his  weight  was  reduced  eighty  pounds. 
Since  then  he  has  had  two  or  three  similar  atacks,  the  last 
having  occurred  two  days  before  his  entrance  to  the  hospital. 
It  was  ushered  in  by  nausea,  and  began  shortly  after  dinner, 
continuing  through  the  day  and  night. 

The  physical  examination  showed  the  patient  to  be  a  well- 
developed,  muscular  man.  The  pupils  were  equal,  and  re- 
acted to  fight  and  with  accommodation.  The  bodily  tem- 
perature was  normal.  Examination  of  the  heart  showed  a 
soft  systolic  murmur  at  the  apex,  with  some  accentuation  of 
the  second  aortic.  The  heart  was  but  little,  if  at  all, 
enlarged.  The  abdominal  organs  were  normal.  The  knee- 
jerks  were  lively,  the  skin  reflexes  all  normal.  The  urine 
and  blood  were  normal  in  character ;   and  the  stomach  con- 


84 

tents,  as  obtained  by  the  tube,  were  also  normal.  During 
the  insertion  of  the  tube  the  patient  vomited  a  clear,  thin, 
greenish  mucoid  material,  which  was  similar  to  that  pre- 
viously vomited. 

There  was  no  recurrence  of  the  attacks  while  he  was  in 
the  hospital,  and  he  was  soon  discharged  well.  Two  weeks 
later,  however,  he  was  readmitted  with  the  same  symptoms, 
but  these  again  yielded  completely  to  the  influence  of  rest 
and  hospital  care. 

As  regards  the  personal  history,  the  patient  had  had  syph- 
ilis five  years  ago,  but  had  shown  no  secondary  symptoms. 
He  is  a  man  of  nervous  temperament,  and  is  easily  startled 
and  sometimes  weeps  on  slight  provocation.  He  worked  on 
an  electric  car  at  one  time  and  had  many  nervous  strains ; 
and,  when  these  attacks  began,  he  was  superintendent  of  a 
large  number  of  men  in  a  stable.  His  personal  habits  are 
good,  except  that  he  smokes  a  good  deal  late  at  night  and  has 
been  in  the  habit  of  taking  six  cups  of  tea  daily. 

His  mother  is  said  to  have  had  *'  stomach  trouble,"  and  to 
have  been  of  a  nervous  temperament. 


LXXII. 

This  case  is  that  of  a  woman  fifty-eight  years  of  age,  but 
appearing  much  older.  Her  mother  had  a  tremor  (probably 
senile)  for  some  years  before  her  death,  and  her  grandfather 
is  said  to  have  become  paralyzed  somewhat  after  the  manner 
of  the  patient  herself. 

She  had  had  a  troubled  life,  and  may  have  contracted 
syphilis  from  a  dissolute  husband,  though  the  only  sign  of 
it  was  a  temporary  loss  of  hair  when  she  was  twenty-seven 
years  old. 

For  six  years  she  had  suffered  from  exhausting  and  long- 
continued  attacks  of  diarrhoea,  which  followed  her  to  the 
last.  Three  years  before  her  death  her  skin  began  to 
darken,  first  in  the  normally  pigmented  areas  and  finally  all 


'5 


over,  so  that  her  areolae  became  almost  black,  while  the  rest 
of  the  skin  varied  from  a  light  brown  to  a  dark  chocolate, 
except  that  her  face  and 


lips  were  pale,  her  di- 
arrhoea having  reduced 
her  strength  and  made 
her  excessively  anaemic. 
The  face  was  covered 
with  epidermal  scales  and 
exudation.  In  tempera- 
ment she  was  irritable, 
eccentric,  and  wanting  in 
self-control,  and  showed 
an  indifference  and  un- 
reasonableness, mixed 
with  cunning,  which,  to- 
gether with  the  fact  that 
five  months  before  her 
death  she  had,  after  great 
exhaustion,  a  group  of  at- 
tacks which  seem  to  have 
been  epileptiform  in  char- 
acter, suggested  cerebral 
degeneration. 

Three  years  before  her 
death  she  began  to  have 
paraesthesia  of  the  fingers, 
associated,  after  a  time, 
with  slight  inco-ordina- 
tion.  This  condition 
gradually  increased,  but 
did  not,  for  a  long  time  at 
any  rate,  involve  the  legs. 
Six  months  before  her  death  her  gait  became  rapidly  and 
even  suddenly  feeble  and  ataxic,  while  the  inco-ordination 
of  the  hands  also  increased,  both  symptoms  being  exagger- 
ated by  closure  of  the  eyes. 


^%. 


^^/t 


Case  LXXII. 


86 

She  had  no  lancinating  pains  at  any  time. 

At  the  time  of  the  examination  the  pupils  were  found 
normal.  The  cutaneous  sensibility  of  the  arms  and  legs  was 
greatly  impaired ;  the  knee-jerk  was  exaggerated,  and  ankle- 
clonus  was  present.  The  whole  body  was  greatly  emaci- 
ated and  the  muscles  everywhere  wasted,  but  not  one  group 
more  than  another. 

She  exhibited,  as  she  had  for  a  long  time,  a  ravenous 
appetite  for  certain  articles  of  food,  especially  coffee,  and  a 
perversion  of  taste. 

The  weakness  of  the  legs  increased  slowly,  but  steadily, 
until  in  a  few  months  she  became  paraplegic.  The  limbs 
finally  became  oedematous,  bed  sores  developed  on  the 
sacrum,  and  she  died  from  exhaustion  without  having  shown 
bulbar  symptoms.  Some  degree  of  sensibility  to  prick- 
ing remained,  even  when  the  paraplegia  was  practically 
complete. 

LXXIII. 

Paraplegic  Weakness  and  Inco-ordination. 

A  carpenter,  fifty-five  years  old,  and  who  had  not  lost  a 
day's  work  on  account  of  sickness  for  thirty  years,  came  to 
the  hospital  with  the  following  history :  — 

He  complained  that  six  months  previously  he  had  noticed 
a  sense  of  numbness  in  both  feet,  and  that  the  legs  began  to 
feel  constantly  tired.  This  numbness  had  extended,  so  that 
by  two  months  ago  it  was  up  to  the  knees,  and  there  was  a 
constant  feeling  as  of  ants  crawling  over  his  legs.  Now,  his 
legs  feel  cold  and  numb  up  to  the  hips.  He  has  almost  no 
characteristic  sensation  in  the  rectum  when  the  bowels 
move ;  but  micturition  seems  normal,  except  that  in  very 
cold  weather  there  is  some  involuntary  dribbling  of  urine. 
There  has  been  a  distressing  feeling  about  his  waist  for  the 
past  three  weeks,  as  if  he  were  wearing  a  belt  that  was  too 
tight  for  him,  and  the  onset  of  this  was  accompanied  by  a 


87 

dull,  aching  pain  in  the  lumbar  region,  which  has  persisted 
ever  since.  He  has  been  unsteady  on  his  feet  for  three 
months  past,  and  feels  as  if  he  were  "walking  on  clouds." 
He  cannot  tell  when  he  steps  on  a  stone  or  another  per- 
son's foot,  and  walking  in  a  dark  room  is  very  difficult. 
There  have  been  no  stabbing  pains.  The  sexual  appetite, 
which  was  formerly  strong,  has  now  been  absent  for  six 
months.     The  bowels  are  very  constipated. 

Physical  examination  shows  a  well-developed  man,  of 
good  color.  The  pupils  are  equal,  and  react  normally.  The 
arms  show  no  disturbance  of  sensation  or  motion.  The 
spine  is  straight  and  flexible.  There  is  diminished  sensa- 
tion below  the  knees  of  both  legs,  not  limited  sharply  to  the 
areas  corresponding  to  special  nerves  or  nerve-roots.  There 
is  no  muscular  atrophy  nor  weakness.  The  knee-jerks  and 
plantar  reflexes  are  lively,  and  the  Babinski  phenomenon  is 
present  on  the  left  side.  The  gait  is  markedly  ataxic,  and 
Romberg's  sign  is  present.  The  blood  shows  70  per  cent. 
Hgb. 

He  said,  on  inquiry,  that  he  had  had  a  chancre  seven 
months  before,  but  had  not  been  troubled  by  any  secondary 
symptoms,  and  that  he  had  been  treated  thoroughly,  as  he 
supposed,  for  five  months  after  the  primary  sore  appeared. 

LXXIV. 

Parcesthesia  of  Legs,  Inco-ordination,  Chronic  Diarrhoea, 

Glycosuria. 

The  patient  is  a  lady  of  forty-two  who  has  had  diarrhoea 
much  of  the  time  for  two  years,  together  with  a  considerable 
degree  of  impairment  of  control  of  the  rectal  sphincters. 
Sometimes  she  has  as  many  as  forty  movements  a  day,  and 
occasionally  they  are  offensive.  The  movements  sometimes 
contain  portions  of  intestinal  casts.  There  is  also  a  slight 
and  intermittent  impairment  of  control  of  the  vesical 
sphincter.     There  was  no  sign  of  loss  of  control  until  the 


ss 

diarrhoea  began.  For  a  period  of  nearly  two  years  she  has 
been  troubled  with  an  increasing  numbness  of  the  feet  and 
legs,  which  spread  gradually,  first  to  the  knees,  then  over 
the  thighs.  With  this  numbness,  inco-ordination  of  motion 
came  on,  which  now  is  of  a  high  degree.  The  legs  are 
sometimes  the  seat  of  severe  pains,  seeming  to  be  in  the 
bones,  and  occasionally  of  sharp,  lancinating  pains,  lasting 
only  a  second  or  two.  There  is  no  numbness  of  the  hands 
or  inco-ordination  of  motion  of  the  arms.  The  eyesight  is 
poor,  and  occasionally  she  has  a  pain  over  one  or  the  other 
side  of  the  forehead,  especially  on  the  leftside.  These  are 
apt  to  occur  daily  for  about  two  weeks,  though  without  well- 
marked  periodicity.  At  such  times  the  eyeball  is  generally 
congested,  and  this  appearance  remains  for  some  little  time. 
She  has  also  hallucinations  of  sight,  so  that  "  she  sees 
things  around  the  room ;  and,  when  she  goes  to  them,  they 
are  not  there."  At  one  time  the  feet  were  very  dry  and 
cracked.  Last  summer  she  lost  about  twenty-three  pounds, 
but  now  she  is  gaining.  Her  color  is  pale,  but  not  cachectic ; 
and  examination  of  the  blood  gives  a  low  Hgb.,  but  only 
slight  diminution  in  red  corpuscles. 

The  urine  showed  the  presence  of  sugar. 

Physical  examination  shows  normal  condition  of  the  pupils 
and  eye  muscles,  good  use  of  the  arms  and  hands,  normal 
cardiac  conditions,  normal  abdominal  organs,  so  far  as  can 
be  determined  by  palpation.  There  is  well-marked  Rom- 
berg symptom ;  and  the  knee-jerks  are  absent,  but  hypoton- 
city  is  not  discoverable. 

There  is  a  diffuse  impairment  of  the  sense  of  contact  over 
the  legs,  but  only  of  slight  degree ;  and  also  marked  im- 
pairment of  the  sense  of  position.  There  is  no  well-defined 
loss  of  the  pain  sense. 

At  the  first  and  several  subsequent  examinations,  glyco- 
suria of  considerable  amount  was  discovered. 

Under  treatment  this  patient  improved  very  much,  though 
she  did  not  entirely  recover. 


89 


LXXV. 


Parcesthesia  of  all  Four  Extremities.     Licr eased  Reflexes. 
Muscular  Atrophy  of  Hands  a?id  Arms. 

An  unmarried  lady  of  sixty  consulted  one  of  the  writers  for 
numbness,  prickling,  and  "  heaviness  "  of  hands,  arms,  and 
legs,  which  had  troubled  her  for  nearly  a  year,  and  for  dull 
feeling  in  the  head  which  she  had  had  for  a  much  longer 
time.  Her  gait  was  uncertain,  and  had  been  growing  worse. 
The  prickling  in  the  hands  and  arms  had  at  one  period  dis- 
appeared, and  then  recurred.  She  had  had  some  pretty 
sharp  *'  rheumatic  "  pains  in  the  hollow  of  the  right  foot  and 
in  the  right  leg;  and  there  had  been  some  twitching  of 
the  muscles  of  the  right  hand  and  those  of  the  back,  and 
"  cramps  "  of  the  arms  and  legs  when  placed  in  awkward 
positions.  In  walking,  she  felt  as  if  a  rope  was  tied  around 
the  leg  above  the  knee.  Her  general  health  was  fair,  but 
her  color  had  been  pale  for  the  last  year  or  two. 

On  examination  it  was  found  that  she  walked  with  a 
spastic  gait.  The  Romberg  sign  was  present,  the  knee- 
jerks  and  wrist-jerks  highly  exaggerated,  and  ankle-clonus 
present.  Motions  with  the  hands  were  good,  except  that 
the  strength  was  very  deficient.  The  muscles  over  the 
whole  body  were  small  and  feeble,  and  the  muscles  of  the 
hands  and  arms  were  positively  atrophied.  There  was 
fibrillary  twitching  to  be  seen  over  the  feet,  hands,  and  arms. 

LXXVI. 

Recurrent  Parcesthesia  of  Both  Hands,  associated  with  Pain. 

This  patient  is  a  woman,  thirty-five  years  old,  who  has 
"worked  out"  by  the  day  for  several  years,  her  chief  duties 
being  scrubbing  floors  and  washing  windows,  which  keeps 
her  hands  constantly  immersed  in  hot  or  cold  water.  Dur- 
ing the  past  month  she  has  been  troubled  with  a  sense  of 
numbness  and  tingling  in  both  hands  and  all  her  fingers. 


90 

She  is  able  to  do  her  work,  however,  and  tries  not  to  notice 
it.  In  addition  to  this  she  is  awakened  every  morning  at 
three  or  four  o'clock  by  a  dull  pain,  which  radiates  from  the 
front  and  back  of  her  hands  up  to  the  elbows.  This  pain  is 
somewhat  relieved  if  she  lets  her  arms  hang  down  over  the 
side  of  the  bed,  and  after  a  while  she  is  able  to  sleep  again. 

She  never  has  the  pain  during  the  day-time ;  but  the  numb- 
ness is  continual,  though  it  is  worse  at  night,  so  that  at  times 
she  is  waked  up  by  it,  especially  toward  morning.  She  has 
had  no  infections  disease  since  her  childhood,  and  does  not 
use  alcohol  at  all.  The  bowels  are  somewhat  constipated. 
Her  color  is  good.  The  pupils  are  equal,  and  react  normally. 
The  knee-jerks  are  normal. 

The  hands  show  no  disturbance  of  motion  and  no  impair- 
ment of  sensibility.  The  tension  of  the  radial  arteries  is 
normal.  The  patient  says  that  she  had  a  similar  attack  of 
numbness  of  the  hands  several  months  ago. 

LXXVII. 

Tremor  of  Arm  ajid  Head,  associated  with  Ancesthesia  of  Hand. 

A  bright,  active-looking  girl,  twelve  years  old,  was  sent 
liome  from  school  one  morning  on  account  of  a  violent 
trembling  or  shaking  of  her  right  arm,  which  came  on  her 
suddenly,  and  which  she  was  unable  to  control.  This  lasted 
during  the  entire  day,  but  ceased  when  she  went  to  bed. 
The  same  tremor  returned  three  times  during  the  following 
two  months,  excited  once  by  continued  writing  and  once  by 
a  sudden  fright. 

On  the  day  of  her  first  examination  at  the  hospital  there 
was  no  tremor  of  the  arm,  but  occasional  choreiform  twitch- 
ings  were  present  in  both  arms  and  shoulders.  There  was 
also  a  constant  coarse  rotary  tremor  of  the  head.  The  mus- 
cular power  of  the  hands  was  not  diminished,  but  there  was 
complete  anaesthesia  and  analgesia  of  the  right  hand  over 
the  area  indicated  by  the  diagram.     A  pin  could  be  thrust 


91 

deeply  into  the  skin  over  this  area  without  exciting  any  sen- 
sation whatever.  The  knee-jerks  were  equal  and  exagger- 
ated. Ankle-clonus  was  absent.  A  soft  (functional)  systolic 
murmur  was  heard  over  the  pulmonic  area  of  the  heart. 


Case  LXXVII. 
Showing  Area  of  Anaesthesia. 


After  a  certain  kind  of  electrical  treatment,  lasting  a  few 
minutes,  the  tremor  of  the  head  ceased,  and  sensation  in 
the  right  hand  was  found  to  be  normal.  The  patient  re- 
turned for  treatment  several  times,  and  on  each  occasion  the 
anaesthesia  and  analgesia  were  found  as  in  the  diagram. 
Each  time,  however,  they  passed  off  during  the  application 
of  electricity. 


92 


LXXV      , 

Inco-ordination  of  Limbs  and  of  Speech  Muscles  following 

Mala    a. 

A  man  of  thirty,  of  perfect  \  alth,  had  an  attack  of  ma- 
laria, contracted  in  Washington.  Almost  immediately  after 
this  he  began  to  notice  a  difficulty  in  speech  and  marked 
unsteadiness  in  the  use  of  the  hands  and  in  his  gait.  These 
symptoms  increased  rapidly,  then  diminished  somewhat  in 
severity,  but  did  not  improve  beyond  a  certain  point. 

When  seen  by  me,  about  a  month  after  the  original  attack, 
his  speech  was  markedly  slow,  and  each  syllable  was  pro- 
nounced for  itself  without  reference  to  the  modulation  or  the 
construction  of  the  sentence  as  a  whole.  The  hands,  when 
at  rest,  seemed  free  from  any  motor  disturbance,  but  when 
he  tried  to  carry  out  a  given  movement  an  irregular  oscil- 
lation came  on,  which  increased  with  persistence  of  the  effort. 
From  time  to  time  also  the  head  would  oscillate  slightly 
from  side  to  side,  or  forward  and  backward.  This  was  espe- 
cially true  when  the  patient  was  making  some  special  move- 
ment, but  even  when  he  was  at  rest  a  fine  tremor  of  the 
head  was  visible.  There  were  no  disturbances  of  sensi- 
bility. 

Attempts  at  treatment  were  of  no  avail  during  the  time 
that  the  patient  remained  under  my  observation. 

LXXIX. 

Spastic  Paralysis  and  Ataxia,  of  Gradual  Onset ;  with 
Bulbar  Symptoms. 

A  young  woman  of  nineteen  consulted  me,  in  November, 
1 89 1,  mainly  for  difficulty  in  the  use  of  the  arms  and  legs, 
and  gave  the  following  history :  — 

Fourteen  months  previously  she  had  begun  to  have  lame- 
ness and  numbness  of  the  right  leg.  These  symptoms  soon 
passed  away,  but  again  showed  themselves  a  few  months 


j'ii 


93 

later,  associated  with  numbness  of  the  right  hand,  and  with 
inco»ordination,  or,  rather,  uncertainty,  of  motion.     In  the 
course  of  two  months  she  again  improved,  but  a  little  later 
the  symptoms  returned  as  before,  though  continuing  to  vary 
in  amount.     The  muscles  of  the  face  became  slightly  numb 
and  paralytic,  and    the  articulation    indistinct;    but  at  this 
time  the  signs  were  confined  to  the  left  side.     At  times,  dur- 
ing this  period,  double  vision  came  on,  and  then  passed  away ; 
and  for  about  a  week  she  suffered  from  dizziness.     During 
April  she  had  difficulty  in  swallowing  for  about  a  week.     My 
examination  showed  the  presence  of  static  and  loco-motive 
ataxia  of  both  arms  and  legs.     At  the  same  time  both  knee- 
jerks  were  increased,  and  ankle-clonus  was  present.     There 
was  impairment  of  sensibility,  of  moderate   degree,  as  re- 
gards position,  temperature,  touch,  and  pricking,  over  the 
feet.     The  left  leg  and  foot  were  in  all  respects  more  af- 
fected than  the  right.     The  conditions  still  seemed  to  vary 
considerably  between  different  examinations;    but  in   gen- 
eral she  grew  worse,  so  that  before  long  it  was  impossible 
for  her  to  walk   alone,  partly  from   spastic    and  paralytic 
troubles,  partly  from  inco-ordination.     The  articulatory  de- 
fect, however,  did  not  increase,  perhaps  even  diminished. 
While  in  this  condition,  wholly  unable  to  walk  alone  under 
ordinary  circumstances,  she  had   an   attack  of  somnambu- 
lism   to   which    she   was    subject,    and   in   that    state    she 
walked  across  the  room.     Subsequently,  under  the  influence 
of   a   semi-hypnotic  treatment,   her   power   of   walking  im- 
proved to  some  extent,  so  that  she  was  able  to  get  about  the 
room  by  the  aid  of  chairs.     Eventually,  however,  she  grew 
worse,   and  died   from    an   intercurrent   infectious   disease, 
somewhat   more   than  three   years   after   the   onset  of   the 
symptoms. 

The  examination  of  the  central  nervous  system,  as  made 
by  Dr.  Taylor,  will  be  reported  on  during  the  discussion  of 
the  case. 


94 


LXXX. 

Weakness  and  Inco-ordination  of  Limbs,  of  Acute  Onset; 
Severe  A7KEmia. 

This  patient  was  an  elderly  lady,  of  seventy,  who  at  the 
time  of  the  first  examination  was  confined  to  bed  with  great 
weakness  and  inco-ordination  of  the  limbs,  associated  with  a 
sense  of  numbness  of  the  hands  and  feet.  She  looked  pale 
and  poorly  nourished ;  but  this  had  been  present  for  a  long 
time,  and  the  examination  of  the  blood  had  indicated  only  a 
moderate,  secondary  anaemia. 

On  inquiry  it  was  learned  that  about  three  months  previ- 
ously she  had  had  an  attack  of  sore  throat,  called  tonsillitis, 
though  there  were  white  spots  on  the  tonsils  at  first,  which 
disappeared  in  the  course  of  a  few  days.  She  was  said  not 
to  have  been  very  sick ;  but  the  temperature  on  the  first  day 
was  103,  after  which  it  gradually  decreased.  There  had  been 
some  difiiculty  in  swallowing,  but  it  was  reported  that  the 
cervical  glands  were  not  swollen.  She  seemed  to  be  in  the 
way  of  recovering  from  this  attack,  but,  after  she  had  been 
fairly  well  for  a  week  the  difficulty  in  swallowing  returned. 
This  difficulty  soon  began  to  pass  away,  however,  and  disap- 
peared in  the  course  of  three  weeks,.  One  week  later  she 
had  pain  in  the  right  side,  followed  by  slight  jaundice ;  and 
at  the  end  of  another  week  paraesthesia  of  the  hands  and  feet 
began  to  come  on,  attended  by  inco-ordination  as  above 
noted,  and  this  soon  became  so  severe  that  she  could  not 
walk  alone. 

At  the  examination,  all  motions  were  possible,  but  the 
strength  was  very  feeble  and  the  movements  were  very  awk- 
ward. The  sensibility  of  the  skin  was  greatly  diminished  in 
all  its  modes  over  both  the  hands  and  the  feet,  especially  the 
latter.  The  sense  of  position  was  very  poor, —  in  fact, 
almost  lost,  so  far  as  the  fingers  and  toes  were  concerned. 
The  knee-jerks  were  absent  on  both  sides.  The  pupillary 
reactions  were  normal.     The  sphincters  were  unaffected. 


^^^.y^J^AA  ^fyr^^"^^   a^^M^}^ 


95 

These  symptoms  eventually  passed  slowly  away,  and  the 
patient  recovered  entirely  in  the  course  of  six  months. 

LXXXI. 

Parcesthesia^  Progressive    Weakness  and  Ataxia,  involving  all 
Four  Limbs  and  ending  fatally  ;  High  Degree  of  Ancemia. 

This  patient  was  a  woman  of  fifty.  It  was  said  that  she 
had  always  been  pale  in  color  and  somewhat  self-willed  and 
excitable  in  disposition,  though  otherwise  in  fairly  good 
health  until  about  four  years  before  the  first  examination 
was  made.  Two  years  previously  to  that  she  had  sustained 
a  severe  loss  in  the  death  of  a  near  relative,  to  whom  she 
was  deeply  attached  and  on  whose  companionship,  in  fact, 
she  was  very  dependent ;  and  it  is  probable  that  the  severe 
shock  of  this  experience  was  one  of  the  exciting  causes  of  her 
later  illness.  The  prostration  of  this  shock  was  followed,  after 
a  time,  by  a  tendency  to  insomnia,  and  this  by  a  gradual  loss 
of  flesh  and  color.  Even  as  long  as  three  years  before  the 
first  examination  she  began  to  notice  "  thrilling  "  sensations 
in  the  ends  of  the  fingers  when  struck  together,  and  also 
"  drawn  "  feelings  in  the  hips  and  knees,  and  across  the 
abdomen,  on  going  upstairs.  This  last  feeling  was  in- 
creased by  walking,  which  she  consequently  used  to  dread. 
These  parsesthesias  were  followed  after  a  year  by  gradually 
increasing  difficulty  in  walking  and  in  the  use  of  the  hands, 
at  first  mainly  of  ataxic  character,  finally  paralytic.  The 
whole  duration  of  the  motor  symptoms  was  about  two  years. 
In  the  last  year  or  year  and  a  half  of  her  fife  both  the 
anaemia  and  the  nervous  symptoms,  including  the  mental  ex- 
citability, steadily  gained  ground.  Two  blood  examinations, 
made  respectively  about  six  and  three  months  before  her 
death,  showed  a  reduction  of  the  red  cells  to  about  2,000,000, 
and  the  Hb.  to  40  per  cent.  There  was  also  well-marked 
poikilocytosis  and  megalocytosis.  As  regards  the  mental 
condition,  it  may  be  said  that  at  quite  an  early  period  in  her 


q6 


>C>, 


a>. 


'^^ 


Case  LXXXI. 


97 

illness  she  had  had  a  difficulty  in  expressing  herself,  which 
does  not  appear  to  have  been  due  to  a  localized  cerebral 
lesion,  but  rather  to  the  anaemic  condition  of  the  brain.  This 
did  not  return  in  a  distinct  form,  though,  when  fatigued  or 
embarrassed,  she  would  sometimes  have  slight  trouble  in 
finding  her  words.  In  general,  her  memory  remained  good ; 
but  she  was  subject  to  violent  outbreaks  of  passion  under 
slight  provocation,  and  showed  considerable  lack  of  judg- 
ment as  to  her  own  condition  and  her  obligations  to  those 
around  her.  Except  in  these  respects,  she  retained  a  high 
degree  of  keenness  to  the  last,  even  at  a  time  when  she  was 
bloodless  from  pallor  and  scarcely  capable  of  a  movement  of 
hand  or  foot.  Toward  the  end  the  limbs  became  extremely 
oedematous. 

LXXXII. 

Pragressive  Parcesthesia  and  Weakness  of  Lii7ibs ;  with 
Exhausting  Illness. 

This  patient,  who  was  a  lady  of  fifty-two,  had  always 
been  anaemic,  easily  worried  and  overworked,  and  had  had 
a  real  and  constant  cause  of  worry  for  many  years.  In 
1882  she  had  a  fall,  striking  on  her  back,  and  in  1883  a 
long-continued  and  severe  bronchitis.  In  1890  she  had 
considerable  diarrhoea  and  nausea,  which  continued  off  and 
on  for  six  months,  when  she  had  grippe,  and  this  in  its  turn 
was  again  followed  by  nausea  and  diarrhoea.  In  1892  she 
had  a  severe  hemorrhage  from  some  part  of  the  urinary 
passages,  and  after  this  was  severely  blanched  for  many 
months.  From  this  time  to  1896,  when  she  died,  nausea 
and  vomiting,  induced  by  fatigue  or  worry,  were  of  frequent 
occurrence.  During  this  period  "numbness"  of  the  arm 
was  occasionally  complained  of;  and  in  1895  this  symptom 
was  specifically  noted  as  affecting  the  legs  and  sometimes 
extending  as  high  as  the  waist,  though  the  slightest  touch 
from  another  person's  finger  was  felt  in  the  affected  parts. 
On  April  16  of  this  year  the  blood  was  examined  for  per- 


98 


o  - 

Case  LXXXII. 


99 

nicious  anaemia,  but  with  negative  results.  Tremor  in  the 
left  and  then  in  the  right  arm  was  next  noted.  The  pupils 
were  found  to  have  a  normal  reaction.  She  died  finally  on 
June  8,  1896,  from  exhaustion,  due  mainly  to  the  continued 
attacks  of  vomiting. 

LXXXIII. 

Paroxysms  of  Abdomi7ial  Pain  ;  Paralysis  a7id  Atrophy  of 
Certaiii  Groups  of  Muscles  of  Arms  and  Legs. 

A  mason,  thirty-six  years  old  and  of  good  habits,  had  been 
subject  to  attacks  of  abdominal  pain  for  five  weeks.  These 
attacks  would  last  several  days,  and  he  would  roll  about  the 
bed  and  cry  out,  so  great  was  the  severity  of  the  pain. 
There  was  vomiting  with  some  of  the  attacks,  and  the  bowels 
were  constipated.  Pressure  over  the  abdomen  relieved  the 
pain  somewhat. 

About  two  weeks  before  the  time  when  he  was  first  seen,  he 
was  seized  with  a  chill,  followed  by  fever  and  sweating,  and 
this  attack  was  followed  two  days  later  by  another  of  similar 
sort.  A  few  days  after  these  paroxysms  first  appeared  he 
began  to  lose  strength  in  his  arms  ;  and  this  weakness  has 
increased  ever  since,  so  that  during  the  past  week  he  has 
been  unable  to  dress  himself.  At  about  the  time  the  trouble 
with  his  arms  began  he  had  more  or  less  dull  aching  pain 
in  both  legs,  followed  in  a  few  days  by  weakness  of  such  a 
degree  that  walking  became  so  difficult  that  on  one  occasion 
he  fell  in  the  street  and  was  unable  to  get  up  alone. 

Examination  showed  moderate  pallor  of  the  skin  and 
mucous  membranes.  There  was  almost  complete  loss  of 
power,  and  some  atrophy,  of  all  the  muscles  of  both  arms, 
from  the  shoulder  down,  except  the  supinator  longus  and 
the  long  flexors  of  the  hand.  The  atrophy  was  most  marked 
over  the  extensor  surfaces.  Both  legs  showed  marked  loss 
of  strength  of  the  extensor  muscles.  There  was  no  impair- 
ment of  sensibility  to  be  made  out,  and  no  disturbance  of 
micturition.     The    knee-jerks,  and  also  superficial  reflexes, 


100 

were  diminished.  There  was  no  elevation  of  temperature. 
The  blood  examination  showed  Hgb.  45  per  cent.,  reds, 
4,240,000  and  whites,  8,000,  while  many  red  corpuscles  con- 
tained Grawitz  granules.  Plasmodia  of  tertian  malaria  were 
present.  The  urine  contained  a  trace  of  albumen,  and  the 
sp.  gr.  was  1029.  The  sediment  showed  numerous  hyaline 
and  finely  granular  casts  and  renal  cells,  and  many  uric  acid 
crystals. 

Upon  investigation  it  was  found  that  the  patient's  wife 
and  son  had  been  subject  to  attacks  of  severe  abdominal 
"cramps"  and  obstinate  constipation,  while  a  seven-year-old 
girl  had  suffered  from  similar  "cramps"  and  had  recently 
had  an  epileptiform  convulsion  lasting  twenty  minutes.  Also 
a  two  months'  old  baby  had  a  number  of  attacks  of  carpo- 
pedal  spasm  and  frequent  convulsions.  The  blood  of  all 
these  patients  showed  a  high  Hgb.,  and  there  were  frequent 
Grawitz  granules  in  the  red  corpuscles. 

The  patient  improved  gradually  under  treatment,  and  by 
the  end  of  nine  months  had  recovered  the  strength  of  all  his 
muscles  except  the  extensors  of  both  forearms,  where  there 
was  still  loss  of  power  and  marked  atrophy. 

LXXXIV. 

Progressive  ParcBsthesia  and  Loss  of  Power,  resulting  in 
Paralysis  of  Respiratory  Muscles. 

The  following  are  the  notes  taken  at  the  time  the  patient 
was  first  seen : — 

Single  man,  twenty-eight  years  old,  working  on  the  Boston 
Elevated  Railroad.  Previous  history  negative,  except  that 
he  had  gonorrhoea  two  years  before,  with  an  acute  exacer- 
bation one  month  ago,  "without  any  venereal  exposure  as  a 
cause."  During  the  past  three  weeks  he  has  been  troubled 
by  a  cough  with  some  yellow  expectoration,  but  has  kept 
about  his  work  as  usual.  Seven  days  ago  he  noticed  that 
the  fingers  of  the  left  hand  felt  numb  and  prickly.     The 


lOI 


next  morning  both  hands  and  both  feet  felt  numb ;  but  he 
did  not  pay  much  attention  to  this,  and  worked  all  day  climb- 
ing up  and  down  a  ladder.     On  the  morning  of  the  third 
day  this  same  paraesthesia  had  extended  to  his  knees,  while 
the   arms   were  involved  to  the  elbows.     Nevertheless,  he 
could  use  his  hmbs  and  started  to  work,  but  had  to  give  up 
after  an  hour  on    account   of   sharp   stinging   pain  in   his 
calves  and  a  general  sense  of  weakness.     He  went  to  bed, 
and  has  remained  there  ever  since,  though  he  did  not  notice 
any  change   until  he   tried  to  get   up,  on  the  fourth  day. 
Then'  he  found  that  he  had  lost  power  in  his  arms  and 
legs.     During  the  forty-eight  hours  since  then  there  has  been 
no  progression  of  the  paralysis  noticed,  but  the  patient  has 
been  troubled  with  stabbing  pains  in  the  legs  and  back,  and 
to  a  less  extent  in  the  arms.     There  has  been  no  difficulty 
in  respiration,  but  during  the  past  twenty-four  hours  he  has 
found  it  hard  to  get  strength  enough  into  his  cough  to  raise 
sputum  from  his  throat.     Swallowing  is  not  affected,  but  he 
has  vomited  several  times  to-day.     The  action  of  the  bladder 
is  not  involved,   but  the  bowels  have  not  moved  for  four 
days. 

The  patient  is  a  well-developed  and  nourished  man.  His 
legs  are  completely  paralyzed,  and  no  movements  of  the 
upper  extremities  are  possible  except  to  a  slight  degree  at 
the  wrists.  The  respiration  is  shallow  and  somewhat 
labored,  and  seems  to  be  wholly  diaphragmatic.  He  fre- 
quently coughs  weakly ;  and,  if  aided  by  quick  pressure  over 
the  sides  of  the  thorax  at  the  time  of  the  cough,  he  raises 
frothy,  purulent  sputum.  The  movements  of  the  head  are 
preserved.  The  pupils  are  normal  and  the  eye  muscles 
unaffected.  The  patellar  and  plantar  reflexes  are  absent. 
The  heart  is  rapid,  but  the  sounds  are  normal.  The  lungs 
show  numerous  fine  moist  rales  throughout.  Temperature, 
100.4  F.;  pulse,  114;  resp.,  24. 

There  was  no  marked  disturbance  of  sensation  ;  but,  before 
careful  tests  could  be  made,  the  breathing  suddenly  ceased. 


102 

Artificial  respiration  was  performed,  and  by  this  means  life 
was  sustained  for  several  hours,  death  then  resulting  from 
gradual  failure  of  the  heart.  The  urine  was  normal.  The 
blood  showed  34,600  whites  per  cu.  m.m.,  and  the  sputum 
contained  large  numbers  of  pneumococci. 

LXXXV. 

Progressive^   Spreading  Paralysis ;  Death, 

A  young  girl,  fifteen  years  old,  who  had  previously  been 
perfectly  well,  found  herself,  one  morning  in  December, 
very  weak  in  the  legs.  She  improved  a  little,  and  went  to 
school ;  but  while  there  the  weakness  increased,  so  that  she 
returned  home.  In  the  afternoon  she  went  out  to  drive. 
The  next  day  she  was  worse,  in  that  the  arms  had  become 
weak  as  well  as  the  legs,  though  sometimes  improving 
slightly.  On  the  second  day  she  began  to  have  difficulty  in 
swallowing  and  in  breathing,  and  her  speech  became  slightly 
labored.  There  had  been  no  sensory  symptoms  except  a 
little  pain  in  the  right  side  and  across  the  upper  part  of  the 
chest,  and  also  in  her  hips.  She  was  seen  by  me  on  the 
fifth  day  of  her  illness.  She  then  lay  on  her  back  with 
the  arms  flexed,  and  the  hands  thrown  back  with  the  palms 
up.  There  was  no  motion  at  the  hand  or  wrist.  Flexion  at 
the  elbow  was  possible,  though  feeble ;  extension  impossible. 
Rotation  outward  at  the  shoulder  was  possible,  though 
feeble ;  rotation  inward,  almost  impossible.  Respiration 
was  rapid  (33  to  the  minute),  superficial,  and  exclusively 
diaphragmatic,  except  for  the  help  of  the  cervical  muscles. 
The  cheeks  were  flushed.  All  motions  of  the  head  and  eyes 
were  free,  but  the  pupils  responded  very  little,  if  at  all,  to 
light,  and  were  rather  contracted.  The  temperature  was 
normal  at  the  time  of  the  examination,  but  was  reported  as 
having  been  103°  F.  during  a  part  of  the  previous  day. 
The  fundus  of  the  eye  was  normal.  There  was  no  paralysis 
of  the  sphincters.     The  reflexes,  both  deep  and  superficial, 


I03 


were  absent.  There  was,  apparently,  no  impairment  of  sen^ 
sibility ;  the  patient  felt  a  touch  or  a  prick  with  ease  over 
every  part  of  the  body.  At  one  time  there  had  been  reten- 
tion of  the  urine,  but  this  was  not  then  present.  The  patient 
had  been  perfectly  clear  in  her  mind,  but  was  much  annoyed 
by  the  collection  in  her  mouth  of  mucus  and  saliva  which 
she  could  not  swallow.  She  grew  steadily  worse,  and  died 
on  the  seventh  day  of  the  illness.  It  was  said  that  on  the 
evening  before  she  had  had  a  slight  vomiting  attack,  and 
that  she  then  regained  to  some  extent  the  power  of  swallow- 
ing which  she  had  previously  lost.  Death  occurred  sud- 
denly, without  warning.     No  examination  was  allowed. 

LXXXVI. 

Numbness,  Weakness,  and  Atrophy  of  Arms  and  Legs,  with 
Atrophy;  Improvement  to  a  Certain  Point  only,  then  New 
Symptoms. 

A  middle-aged  man  consulted  me  some  years  ago,  during 
a  severe  epidemic  of  the  grippe,  for  extreme  weakness  of 
the  arms  and  legs,  and  gave  the  following  history.     He  had 
had,  he  said,  an  acute  catarrhal  attack,  but  was  getting  over 
It,  so  that  he  was  feeling  well  and  able  to  walk  out,  when 
one  day,  as  he  was  crossing  the  street,  one  knee  gave  way 
and  presently  the  other.     This  was  quickly  followed  by  a 
weakness  of  the  hands  and  arms,  associated  with  pain  and 
numbness.     When  I  saw  him,  there  was  partial  paralysis  of 
all  the  muscles  moving  the  fingers  and  hands,  but  especially 
the  extensors.     This   was    associated   with  a   high    degree 
of  muscular  atrophy,  and  also  with  marked  sweating  of  the 
skin  and  tenderness  of  the  muscular  masses.     He   looked 
excessively  ill;  but,  beheving  the  disease  to  be  acute  neuritis, 
I  gave  a  favorable  prognosis.     This  case  was  peculiar  from' 
the  fact  that  a  considerable  degree  of  inco-ordination  was 
present,   affecting   both  arms   and  legs ;   but  this,  too,  is  a 
symptom  sometimes  seen  in  multiple  neuritis.     I    did   not 


104 

see  the  patient  again  for  about  two  years,  though  I  had  learned 
that  he  had  in  some  respects  improved.  When  he  finally 
called  upon  me,  all  acute  signs  had  disappeared,  and  like- 
wise the  atrophy  of  the  muscles.  On  the  other  hand,  he 
gave  a  history  of  having  had  lancinating  pains  and  slight 
disorders  of  micturition.  An  examination  of  the  pupils 
showed  a  well-marked  Argyll- Robertson  reaction,  besides 
inequality  and  irregularity.  I  then  ascertained  that  he  had 
had  syphilis  some  years  before.  The  inco-ordination  had 
persisted,  and  increased  in  severity  and  it  was  increased  by 
closure  of  the  eyes.     The  knee-jerks  were  not  obtainable. 

LXXXVII. 

Pain^  Impairment  of  Sensibility^  Paralysis^  and  Atrophy,  of 
the  Muscles  of  Arms  and  Legs,  especially  those  below  the 
Elbows  and  Knees  ;  Cerebral  Complications. 

(From  Ross  and  Bury,  p.  126).  Female  patient,  thirty- 
six  years  old.  She  comes  to  the  hospital  for  paralysis  of  the 
hands  and  feet,  the  details  of  which  are  given  below.  She 
states  that  for  several  years  she  had  suffered  at  times  from 
cramps  in  the  legs  and  tingling  in  the  hands  and  feet.  The 
present  weakness  of  the  legs  began  about  a  month  ago, 
the  hands  becoming  helpless  considerably  later  and  rather 
suddenly.  The  results  of  the  physical  examination  are  in 
essential  respects  as  follows :  The  muscles  are  everywhere 
flabby  and  apparently  wasted,  although  this  condition  is 
sometimes  concealed  by  subcutaneous  fat.  There  is  a  little 
pitting  on  pressure  over  the  ankles.  Taking  the  movements 
from  above  downward,  those  at  the  shoulder  can  be  per- 
formed with  some  force ;  and  flexion  at  the  elbow  is  moder- 
ately strong.  Extension  at  the  elbow  is  relatively  weak. 
All  movements  of  the  hands  and  fingers  are  lost,  except  for 
feeble  flexion  of  the  fingers.  The  thighs  can  be  flexed 
slightly,  and  the  legs  flexed  feebly  at  the  knee.  All  other 
motions  of  the  legs,  and  all  motions  of  the  feet  and  toes  are 


I05 

lost.  There  is  nystagmus  on  fixation,  and  oscillation  on 
lateral  rotation.  The  pupillary  reactions  are  present,  but 
sluggish.  The  wrist-jerks  and  knee-jerks  are  absent,  and 
plantar  reflexes  likewise.  Pain  is  complained  of  in  the  fore- 
arm and  about  the  shoulders,  and  tingling  is  felt  in  the 
hands  and  feet.  The  sense  of  contact  is  greatly  diminished 
for  the  hands  and  feet ;  the  prick  of  a  pin  is  felt,  but  de- 
layed. The  sense  of  position  and  passive  motion  is  re- 
tained. There  is  very  marked  tenderness  on  deep  pressure 
over  the  soles  of  the  feet  and  over  the  muscular  masses  of 
the  legs  and  arms.  The  irritability  of  the  nerve-muscle 
systems  to  faradic  electricity  is  diminished  about  in  propor- 
tion to  the  severity  of  the  local  changes,  and  is  absent  for 
the  extensor  longus  dig.  pedis  and  the  peronei  (strong  cur- 
rent). The  heart,  lungs,  and  abdominal  organs  are  normal. 
Urine  normal,  temperature  normal.  The  memory  is  defec- 
tive, and  the  patient  is  troubled  with  hallucinations  and 
nightmares.  No  sign  of  improvement  had  shown  itself  by 
the  end  of  a  month. 

LXXXVIII. 

^^  Numbness,^''   Soreness,   and    Weakness   of  Arms  and  Legs, 

after  Typhoid. 

A  middle-aged  man,  of  excellent  previous  health,  had  a 
typical  attack  of  typhoid  fever  in  November,  1887.  He 
was  in  bed  for  three  months,  and  during  part  of  the  time  was 
very  ill,  but  he  did  not  take  any  large  quantity  of  alcohol. 
At  the  end  of  the  first  month  he  began  to  notice  a  soreness 
of  the  legs  through  their  whole  extent,  with  marked  tender- 
ness on  deep  pressure  over  the  muscular  masses,  especially 
the  quadriceps  and  the  calf  muscles.  There  was  also  a 
sense  of  numbness  in  the  third  and  fourth  fingers  of  the 
right  hand,  but  no  soreness  of  the  right  arm.  The  feet, 
also,  felt  numb  and  uncomfortable,  especially  the  under  sur- 
face of  the  toes.  At  a  later  period,  during  convalescence, 
the  feet  hurt  him  on  walking,  and  oblong  patches  of  numb- 


io6 

ness  made  their  appearance  on  the  outer  surfaces  of  both 
thighs  (meralgia  paraesthetica).  During  the  height  of  the 
illness  the  legs  became  much  wasted,  and  slight  but  well- 
marked  impairment  of  sensibility  to  touch  was  present  over 
the  ball  of  the  foot  on  both  sides,  the  toes,  the  little  finger 
on  one  hand,  and  an  area,  four  by  six  inches  large,  along 
the  outer  surface  of  the  left  thigh.  Well  marked  R.  D.  was 
found  on  electrical  examination  of  the  interosseous  muscles 
of  the  feet.  The  patient  improved  gradually,  and  recovered 
completely  after  some  months. 

LXXXIX. 

Weakness  of  A?'?ns  a?id  Legs  with  Extensive  Parcesthesia. 

This  patient  was  an  unmarried  business  man,  forty  years 
old.  His  illness  began  in  January,  1888,  with  numbness 
and  tingling  sensations  in  feet  and  hands,  followed  very 
quickly  by  muscular  weakness.  Even  before  this  he  had 
noticed  for  some  little  time  that  his  right  arm  would  "go  to 
sleep  "  easily  at  night,  and  this  symptom  would  be  brought 
on  by  lying  on  the  left  side.  At  the  first  examination,  which 
was  on  January  11,  he  complained  mainly  of  this  sense  of 
numbness  which  then  reached  as  high  as  the  waist,  and  in- 
volved the  perinaeum  and  the  genitals.  The  foreskin  was 
almost  devoid  of  sensibility.  The  fingers  were  also  numb 
and  prickly,  and  for  the  past  few  days  there  had  been  a 
stiff  feeling  in  the  face,  especially  the  cheeks  and  upper 
lip,  and  the  tongue  had  felt  thick.  He  thought  his  eye- 
sight was  not  quite  so  clear  as  formerly,  but  there  was 
no  distinct  double  vision.  (The  patient  had  been  liable 
for  a  long  time  to  occasional  attacks  of  loss  of  half  the 
field  of  vision,  lasting  for  half  an  hour  or  more,  and  fol- 
lowed by  a  severe  headache.  Other  members  of  the  fam- 
ily had  had  similar  attacks.)  The  sphincters  were  not 
involved.  There  had  been  no  pain  anywhere,  though  some 
of  his  muscles  felt  sore  on  pressure.     He  had  felt  rather 


10/ 

heavy  for  a  few  days,  but  had  had  no  marked  fever  and  no 
mental  symptoms. 

Previous  History. —  The  patient  had  had  gonorrhoea,  but 
never  a  chancre  to  his  knowledge.  He  had  been  in  the 
habit  of  smoking  and  drinking  heavily,  sometimes  to  the 
amount  of  six  small  tumblerfuls  of  liquor  a  day.  He  had 
had  rheumatic  fever  as  a  child,  but  there  had  been  no  subse- 
quent attacks.  Three  weeks  before  the  present  symptoms 
he  had  been  exposed  in  a  heavy  rain. 

Physical  Examination. —  There  was  great  difficulty  in 
going  up  and  down  stairs,  and  this  was  referred  especially 
to  weakness  of  the  thighs.  Dorsal  flexion  of  the  feet  was 
imperfect,  and  all  the  movements  of  the  legs  were  weak 
though  none  were  lost.  He  could  raise  himself  on  the  toes 
of  both  feet  together,  but  not  on  the  toes  of  one  alone.  Both 
extension  and  flexion  of  the  hands  and  feet  were  somewhat 
feeble,  about  two-thirds  as  strong  as  usual  as  measured  by 
the  dynamometer. 

The  urine  contained  no  sugar,  but  a  very  sUght  trace  of 
albumen.  Sp.  gr.  was  1031.  The  heart's  action  was  slightly 
intermittent,  but  otherwise  normal ;  and  there  were  no 
murmurs.  The  muscles  of  the  calves  and  thighs,  on  both 
sides,  and,  in  less  degree,  the  muscles  of  the  forearm  were 
tender  on  deep  pressure.  There  was  a  wide-spread  impair- 
ment of  sensibility  to  contact  and  pricking  over  the  hands 
and  feet,  though  this  amounted  to  no  more  than  that  the  sen- 
sations appeared  to  him  somewhat  unnatural.  He  could 
stand  well  with  the  eyes  closed.  The  knee-jerks  were  absent 
on  both  sides. 

The  electrical  examination  showed  a  quantitative  impair- 
ment of  reaction  of  the  affected  muscles  of  moderate  degree. 
No  R.  D.  The  parts  where  this  impairment  of  reaction  was 
especially  studied  were  the  thenar  muscles  [F,  108  m.m. 
(normal,  120  m.m.);  (G,  2  m.a.  (normal,  i  m.a)];  and  the 
peroneal  nerve  [F.  90  m.m.  (normal,  120  m.m.)].  The  re- 
action of  the  vastus  internus  seemed  to  be  about  normal. 


io8 

The  course  of  the  case  was  one  of  gradual  improvement. 
This  was  only  interrupted  by  the  occurrence  of  inflamma- 
tion of  the  right  knee,  of  moderate  intensity,  which  came  on 
in  the  fourth  month  of  the  illness,  and  lasted  about  three 
weeks.  The  whole  duration  of  the  illness  was  about  six 
months. 

XC. 

Diffuse  Paralyses  of  Sensation  and  Motion  of  Long  Duration  ; 
Nearly  Complete  Recovery. 

This  case  is  that  of  a  female  patient,  twenty-eight  years 
old,  unmarried,  nurse  by  profession,  who  came  to  the  Massa- 
chusetts Hospital  in  1896  with  a  high  degree  of  general 
weakness  of  both  arms  and  legs,  and  marked  impairment  of 
sensibility,  of  such  a  kind  that  the  sense  of  contact  was  much 
less  affected  than  the  sense  of  pain  as  developed  by  pricking 
with  a  needle.  These  symptoms  subsequently  passed  away 
to  a  great  extent,  and  in  February,  1900,  I  had  the  oppor- 
tunity of  examining  her  again,  which  I  did  with  the  follow- 
ing result :  It  appeared  that  in  childhood  she  had  been 
nervous,  though  active  and  intelligent,  and  that  she  had  had 
an  attack  of  chorea  during  that  period.  When  eight  years 
old  she  had  scarlet  fever,  and  at  about  the  same  time  a  pain 
in  the  right  elbow  called  "rheumatic."  This  was  attended 
by  a  drawing  up  of  the  little  finger  of  the  right  hand.  In 
1890  or  189 1  she  had  had  a  severe  shock  due  to  an  insane 
patient  jumping  on  her  while  she  was  in  a  stooping  position. 
She  was  confined  to  the  bed  for  three  months  by  this,  and 
became  excessively  weak,  but  seemed  eventually  to  recover. 
In  1893  she  had  typhoid  fever,  and  while  still  sick  in  bed 
she  was  attacked  with  pain  and  paralysis  of  the  right  arm, 
which  came  on  very  rapidly.  The  great  toe  of  the  right 
foot  became  paralyzed  at  the  same  time.  Eventually,  as 
will  be  seen,  the  whole  of  the  right  leg,  and,  in  fact,  all  the 
limbs,  became  involved,  but  this  was  not  until  considerably 
later.     During  the  next  six  or  seven  months  she  dragged 


109 

herself  about,  though  with  difficulty  on   account  of  general 
weakness.     The  paralysis  of  the  right  arm  had  been  so  great 
that  all  motions  of  the  hand  had  been  lost,  and  most  of  those 
of  the  elbow  and  shoulder  but  for  a  time  there  was  an  im- 
provement, so  that  she  could  move  the  arm  at  the  shoulder, 
though   she  could  not  use  the  hand.     Gradually,  her  legs 
became  very  weak,  especially  the  right.     The  sensibihty  of 
the  most  affected  parts  had  been  seriously  impaired  from  the 
beginning,  so  that,  for  example,  the  right  foot  and  hand  felt 
"numb  and  dead,"  and  the  sensibility  of  the  skin  became 
greatly  impaired  both  as  regards  contact,  temperature,  and 
pain.     For  the  next  two  years  she  continued  to  grow  worse, 
until  finally  she  could  not  stand ;  and  it  was  at  this  period 
that  she  came  to  the  Massachusetts  General  Hospital.     The 
left  arm  did  not  become  affected  until  about  a  year  after  the 
feet.     When  the  paralysis  was  at  its  height,  the  motions  of 
the  jaw  became  affected,  so  that  she  had  difficulty  both  in 
articulating  and  masticating,  and  the  trunk  muscles  became 
so  weak  that  a  spinal  curvature  came  on.     She  suffered  also 
from  painful  flexor  spasms  of  the  Hmbs,  including  the  fingers 
and  toes  and  the  muscles  of  the  neck.     For  a  time  there 
was  an  incontinence  of  the  urine,  but  this  was  transient.     In 
March  or  April,  1897,—  /.  e.,  more  than  three  years  after  the 
onset  of  these  symptoms,—  she  began  to  improve,  and  gained 
rather  rapidly,  so  that  in  the  course  of  two  or  three  months 
she  could  walk  a  httle  on  the  street  without  crutches,  though 
still  requiring  a  spHnt  to  keep  her  knees  from  giving  way, 
and  a  corset  to  support  the  body.     This  improvement  has 
continued  up  to  the  present  tim.e,  so  that  now  there  is  but 
Httle  trace  of  the  paralysis  of  sensation  or  motion  except  as 
regards  the  hands.     Here   the  signs  of  "  claw  hands  "  are 
present  in  a  moderate  degree,  though  the  faulty  position  of 
the  fingers  can  be  nearly  corrected  by  a  strong  effort  of  the 
will.     The  two  smaller  fingers  are  permanently  crooked  in 
both  hands  to  some  extent.     The  sensibility  of  the  skin  to 
contact  is  almost  perfect,  though  less   good  over  the  two 


no 

smaller  fingers  than  elsewhere.  On  the  other  hand,  the  prick 
of  a  pin  and  changes  of  temperature  are  scarcely  felt  over 
some  portions  of  the  hand,  especially  in  the  areas  supplied 
exclusively  by  the  ulnar  nerves.  Over  these  portions  a  pin 
may  be  thrust  deeply  into  the  skin  without  exciting  pain, 
whereas  in  other  areas  near  by  the  sensibility  to  pricking 
seems  to  be  normal.  This  impairment  to  sensibihty  is  much 
more  marked  for  the  right  hand  than  for  the  left,  and,  in 
fact,  the  sensibility  to  heat  and  pricking  over  the  right  hand 
and  forearm  is  much  less  acute  than  over  the  left,  though 
above  the  elbow  this  difference  is  not  seen.  The  right  side 
of  the  face  is  also  slightly  less  sensitive  than  the  left  side, 
whereas  there  is  no  difference  between  the  ears  or  the  sides 
of  the  neck.  The  naso-labial  fold  is  a  little  less  marked 
right  than  left,  and  the  right  pupil  is  slightly  larger  than  the 
left.  The  right  hand  is  slightly  dusky  in  color  as  compared 
with  the  left,  and  somewhat  cooler.  The  electrical  reactions 
indicate  a  quantitative  impairment  of  response,  both  to  farad- 
ism  and  galvanism,  of  the  intrinsic  muscles  of  the  right  hand. 
The  spinal  curvature  has  passed  away  mainly,  if  not  en- 
tirely, the  gait  is  normal,  and  the  knee-jerks  are  present 
and  even  rather  lively.  The  patient's  general  health  is  now 
very  good,  so  that  she  can  endure  a  large  amount  of  mental 
and  muscular  exertion  without  suffering. 

XCI. 

Delirium,  Mental  Confusion^  Extensor  Paralysis  of 
Extremities. 

This  patient  was  in  a  disturbed  mental  state  when  first 
examined,  and  no  reliable  history  could  be  obtained.  On 
being  questioned  concerning  her  condition  she  seemed  con- 
fused, and  answered  in  a  rambling  and  incoherent  manner. 
She  was  a  large,  obese,  deeply  jaundiced  woman,  about  forty 
years  of  age.  The  pupils  were  equal,  and  reacted  to  Hght. 
The  voice  could  hardly  be  raised  above  a  hoarse  whisper, 


II I 

and  the  larynx  and  vocal  cords  were  found  to  be  much  red- 
dened. The  tongue  was  dry  and  clean,  and  was  coarsely 
tremulous  when  protruded,  though  it  came  out  straight. 
The  same  coarse  tremor  accompanied  the  movements  of  the 
lips  and  fingers.  The  heart  and  lungs  were  in  a  normal 
state.  The  abdomen  was  full,  and  the  liver  extended  a 
hand's  breadth  below  the  costal  margin,  the  surface  being 
smooth  and  the  edge  even.  The  spleen  seemed  to  be  nor- 
mal in  size.  There  was  no  oedema  of  the  legs^  The  super- 
ficial and  patellar  reflexes  were  absent. 

Tlie  temperature  varied  between  ioo°  F.  and  102'^  F. 
for  several  days,  and  the  mental  confusion  gave  place  to 
a  mild  delirium,  which  became  more  active  at  night,  when 
the  patient  would  spring  up  and  cry  out  in  terror  that  cats, 
or  rats,  were  in  her  bed,  or  that  people  were  after  her. 

About  ten  days  from  the  time  she  was  first  seen  it  was 
noticed  that  she  had  wrist-drop  of  both  hands,  and  was  un- 
able to  extend  the  fingers,  while  one  leg  would  become  flexed 
under  the  other  and  she  would  be  powerless  to  remove  it. 
While  in  this  condition  it  was  impossible  for  her  to  turn 
in  bed. 

Examination  at  this  time  showed  loss  of  sense  of  pain 
over  both  arms  and  legs,  while  there  were  points  tender  to 
deep  pressure  along  the  extensor  surfaces  of  all  four  extremi- 
ties. There  was  no  disturbance  of  the  bladder  or  rectum. 
The  urine  showed  the  presence  of  bile,  but  was  otherwise 
normal,  except  for  signs  of  bile-irritation.  Examination  of 
the  blood  showed  Hgb.  64  per  cent. ;  white  corpuscles,  24,400 
per  c.  m.m. 

While  she  was  still  in  this  condition,  there  was  a  sudden 
rise  in  the  temperature  one  morning,  with  a  rapidly  increas- 
ing rate  of  pulse  and  respiration,  while  the  lips  and  nails 
became  cyanotic.  This  condition  was  associated  with  the 
appearance  of  signs  of  consolidation  over  a  small  area  in  the 
left  lung,  and  the  patient  died  in  a  few  hours.  The  diag- 
nosis was  confirmed  by  autopsy. 


112 


XCII. 

Progressive  Atrophy  of  All  the  External  Muscles  of  the  Body. 

A  young  married  woman,  twenty-seven  years  old,  of  good 
previous  health  and  good  family  history,  presented  herself, 
on  Oct.  lo,  1898,  complaining  of  weakness  of  the  hands, 
especially  of  the  left,  and,  to  a  less  degree,  of  the  legs  also. 
The  hands  had  begun  to  trouble  her  nine  months  before, 
but  for  the  past  two  months  they  had  been  useless  for  any 
sort  of  work,  and  both  writing  and  sewing  had  become 
almost  impossible.  She  had  noticed  for  some  months  past 
that  she  had  stubbed  the  ground  with  her  left  toe,  and  that 
when  she  walked  her  back  had  felt  weak  and  tired.  Crampy 
pains  had  been  felt  in  the  left  arm  from  time  to  time.  All 
the  movements  were  worse  in  cold  weather.  Physical  exam- 
ination showed  an  atrophy  of  all  the  intrinsic  muscles  of  the 
left  hand,  and  to  a  less  extent  those  of  the  right.  There 
was  also  more  or  less  diffuse  atrophy  of  most  of  the  muscles 
of  both  arms,  both  shoulders,  the  back,  and  the  legs.  Fibril- 
lary twitchings  were  seen  in  the  hands,  arms,  and  back 
muscles.  The  knee-jerks  and  wrist-jerks  were  both  exag- 
gerated to  a  high  degree,  and  ankle-clonus  was  present. 
An  electrical  examination  showed  diminution  in  the  faradic 
irritability  about  in  proportion  to  the  atrophy,  and  the  pres- 
ence of  R.  D.  in  the  muscles  which  were  the  most  seriously 
affected,  such  as  those  of  the  left  thenar  eminence.  The 
tongue  deviated  slightly  to  the  left,  and  the  right  side  of  the 
face  was  slightly  atrophic.  From  this  time  on  the  disease 
progressed  slowly,  though  with  brief  intermissions. 

Difficulty  in  articulation  soon  showed  itself ;  and  finally, 
in  1900,  the  muscles  of  the  neck  became  so  weak  that,  if  the 
head  fell  backward,  she  could  not  bring  it  forward,  even 
with  the  aid  of  her  arms. 

While  in  this  condition,  she  became  pregnant;  and  the 
question  arose  whether  abortion  should  be  performed. 


Case  XCIII. 


Case  XCIII. 


Case  XCIII. 


113 


XCIII. 

Gradually  Progressive  Muscular  Wasting,  beginning 
in  the  Hands. 

[Case  reported  by  Dr.  H.  C.  Baldwin.] 

The  patient  whose  condition  is  illustrated  by  the  accom- 
panying picture  was  a  man  of  fifty-two,  who  had  led  an  ex- 
ceedingly active  life,  both  mentally  and  physically.  He 
had  drunk  persistently  and  to  excess,  and  had  had  syphilis. 
His  first  intimation  of  his  sickness  was  in  1889;  ^^^  ^^ 
died  in  1899,  cheerful  and  clear-headed  to  the  last.  The 
thenar  muscles  of  the  right  hand  were  the  first  to  go,  next 
the  supinator  longus,  and  then  the  deltoid.  The  left  arm 
was  attacked  in  similar  fashion  to  the  right,  but  considerably 
later.  He  came  to  the  hospital  in  1893,  and  at  that  time 
he  was  wholly  unable  to  move  either  arms  or  fingers. 
Furthermore,  the  posterior  muscles  of  the  neck  had  be- 
come so  much  affected  that,  unless  he  wore  a  brace,  his  head 
fell  forward  on  his  chest,  and  could  only  be  replaced  by  the 
aid  of  the  hand  or  of  its  own  M^eight.  The  anterior  neck 
muscles  were  but  little  involved,  and  at  that  period  the 
muscles  of  speech,  facial  expression,  and  deglutition,  were 
also  free.  On  the  other  hand,  the  costal  muscles  were  so 
feeble  that  the  breathing  was  almost  wholly  diaphragmatic. 
The  leg  muscles  were  somewhat  wasted,  though  not  nearly 
so  much  as  those  of  the  arms,  and  he  could  still  walk  a 
couple  of  miles  without  difficulty.  He  had  control  over  the 
sphincters  of  the  bladder  and  rectum,  and  the  cardiac  and 
sexual  mechanisms  were  in  a  substantially  normal  condition. 
The  knee-jerk  was  normal  on  the  right  side,  but  exaggerated 
on  the  left ;   and  ankle-clonus  was  present  on  the  left  side. 

He  grew  gradually  worse,  and  died  with  bulbar  symptoms. 
For  two  or  three  years  before  his  death  his  bladder  had 
been  sluggish,  and  he  had  had  no  sexual  desire. 


114 


XCIV. 

JProgressive  Loss  of  Muscular  Poiuer^  gradually  involving 
almost  All  the  Muscles  of  the  Body;  very  Chronic 
Course. 

This  patient,  who  is  still  living,  and  fifty-nine  years  old, 
presented  herself  at  the  Massachusetts  General  Hospital  in 
1887.  Even  then  she  was  so  weak  that  she  had  great  diffi- 
culty in  rising  from  the  chair  to  her  feet.  All  her  muscles 
became  easily  fatigued,  even  those  of  mastication ;  and  she 
suffered  greatly  in  cold  weather,  no  matter  how  warmly  she 
was  dressed.  All  four  limbs  were  involved,  but  the  legs 
more  than  the  arms.  The  muscles  most  affected  were  those 
which  extend  and  flex  the  thighs  on  the  trunk.  These 
muscles  were  greatly  atrophied,  but  even  those  of  the  fore- 
arms, and  of  the  legs  below  the  knee,  were  evidently  altered ; 
and  that,  too,  more  than  their  size  would  indicate,  since  it 
was  evident  that  the  atrophy  was  somewhat  masked  by  the 
presence  of  a  tissue  which  was  not  wholly  muscular.  It  ap- 
peared, on  inquiry,  that  this  patient  had  had  difiiculty  in 
using  her  legs  ever  since  she  was  seventeen  years  old,  and 
perhaps  still  longer.  She  used  then  to  notice  that  she  could 
not  run  as  well  as  other  girls,  and  that  it  was  hard  for  her 
to  step  up  on  to  a  high  step. 

She  said  that  her  father  was  a  strong  and  healthy  man,  but 
had  died  of  cancer  when  sixty  years  old.  Her  mother  was  a 
healthy  woman,  but  had  three  paralytic  shocks,  and  died  at 
the  age  of  eighty-six.  The  father  had  two  brothers,  one  of 
whom  began  at  seventeen  to  be  troubled  with  symptoms 
similar  to  those  of  this  patient ;  and  after  a  time  he  became 
entirely  helpless,  so  that  he  could  not  even  hold  his  head 
erect  or  use  any  part  of  his  body.  He  lived  to  the  age  of 
sixty.  The  other  brother  was  said  to  have  been  well  up  to  the 
age  of  twenty-five,  when  he  had  some  sickness  called  rickets, 
from  which  he  never  recovered.  He,  too,  became  gradually 
helpless,  so  that  he  could  neither  stand  nor  walk  alone.     He 


Case  XCIV 


115 

lived  to  be  nearly  sixty,  and  died  within  a  day  of  his  eldest 
brother.  The  paternal  grandfather  had  a  sister  who  was  a 
cripple.  The  patient  does  not  know  at  just  what  age  her  ill- 
ness came  on,  but  she  became  helpless  like  the  rest,  so  that 
she  could  not  even  get  in  and  out  of  the  bed  alone.  The 
patient  herself  suffers  from  chronic  psoriasis,  which  is  said 
to  have  been  prevalent  in  the  mother's  branch  of  the  family. 

On  physical  examination  it  was  found  that  all  the  muscles 
of  the  extremities  were  small  and  dense,  and  the  contractile 
portions  very  short.  There  was  no  fibrillary  twitching.  In 
consequence  of  the  weakness  of  the  trunk  and  thigh  muscles, 
she  was  unable  to  rise  from  the  ground  or  a  chair  without 
the  aid  of  the  hands  and  arms.  The  weakness  of  the  glutasi 
made  her  gait  very  waddhng  in  character,  and  the  fact  that 
she  could  not  bend  the  foot  at  the  ankle  increased  the  diffi- 
culty of  locomotion.  Nevertheless,  she  is  still  living,  and 
able  to  get  about  more  or  less,  although  it  is  now  forty-two 
years  since  the  first  signs  of  the  difficulty  appeared. 

Repeated  electrical  examinations  were  made,  with  the 
result  that  the  affected  muscles  were  found  to  contract  very 
slowly  and  imperfectly ;  but  there  was  nowhere  any  charac- 
teristic R.D. 

An  excised  piece  of  muscle  showed  the  fibres  to  have  lost 
their  polygonal  shape,  and  to  a  great  extent  their  striation. 
They  were  rounded,  separated  from  each  other  by  wide 
tracts  of  connective  tissue  and  fat,  and  often  broken  down 
at  the  centre,  many  fibres  evidently  having  been  destroyed. 

XCV. 

Numbness  of  Hands  and  Arms,  with  Muscular  Wasting  and 
Trophic  Lesio?is  of  the  Skin  ;  Peculiar  Changes  in  Sensi- 
bility. 

This  patient  was  a  well-developed,  rugged-looking  man, 
twenty-two  years  old,  who  had  worked  in  a  mill  since  boy- 
hood.   He  had  never  been  sick  so  far  as  he  could  remember. 


ii6 


Case  XCV. 
Showing  Area  of  Analgesia  and  Trophic  Skin  Lesions. 


117 


Case   XCV. 
Showing  Area  of  Analgesia  and  Trophic  Skin  Lesions. 


ii8 

He  has  used  tobacco  moderately  and  alcohol  not  at  all,  and 
denied  having  had  venereal  disease. 

Two  years  ago  he  began  to  have  a  sensation  of  numbness 
in  both  hands  and  arms,  extending  up  to  the  shoulders  and 
to  some  extent  onto  the  back. 

One  year  ago  his  hands  and  arms  grew  clumsy,  and  be- 
came so  weak  that  he  was  obliged  to  give  up  work. 

Five  months  ago  the  fingers  of  both  hands  became  flexed, 
so  that  he  was  unable  to  extend  them,  and  this  condition  per- 
sisted for  a  month,  at  the  end  of  which  time  extension  was 
possible  to  some  degree.  At  about  this  period  he  began  to 
have  pain  in  the  backs  of  his  hands,  and  "  sores  "  appeared 
on  his  arms  and  neck.  These  sores  have  remained  ever 
since,  and  seem  to  be  growing  larger.  He  has  lost  twenty 
pounds  in  weight  during  the  past  three  months. 

Physical  examination  shows  the  pupils  to  be  equal,  and 
normal  in  reaction.  There  is  marked  atrophy  of  the  thenar 
and  interosseous  muscles  of  both  hands,  and  the  position  of 
the  fingers  illustrates  a  typical  ''claw  hand."  The  muscles 
of  the  arms  are  flabby  and  atrophied,  while  flexion  and  ex- 
tension at  the  elbow  are  feeble.  Tests  for  sensibility  show  a 
loss  of  power  to  distinguish  heat  from  cold  and  an  absence 
of  pain-sense,  over  the  area  indicated  in  the  diagram,  but 
the  sense  of  touch  is  preserved  over  this  area.  The  re- 
flexes of  the  arms  are  absent.  The  knee-jerks  and  plantar 
reflexes  are  exaggerated.  The  blood  and  urine  are  both 
normal. 

There  are  numerous  crusted  lesions  of  the  skin  scattered 
over  the  hands,  arms,  and  neck,  varying  in  size  and  shape. 

XCVI. 

Atrophy  of  Aluscles  s iLr rounding  the  Shoulder. 

The  patient  whose  case  is  illustrated  by  the  accompanying 
picture  suffered  from  wasting  of  all  the  muscles  concerned 
in  moving  the  right  arm  at  the  shoulder,  and  also  from  pain 


Case  XCVI. 


119 

about  the  shoulder  joint,  and  limitation  of  motion.  Some 
months  previously  he  had  had  a  fall,  in  which  the  shoulder 
was  moderately  injured,  and  as  a  result  of  this  he  had  been 
obliged  to  carry  the  arm  in  a  splint  for  a  number  of  weeks. 
Even  then  there  was  a  great  deal  of  aching  pain  about  the 
shoulder,  but  when  the  bandage  was  removed  and  an  at- 
tempt was  made  to  move  the  arm  this  pain  became  very 
acute,  especially  if  an  effort  was  made  to  carry  the  hand  be- 
hind the  back  or  behind  the  head.  Furthermore,  motion  in 
these  directions  was  absolutely  restricted  to  a  very  consider- 
able degree,  as  if  by  firm  adhesions  about  the  joint.  The 
pain  was  mainly  felt  on  the  outer  surface  of  the  upper  arm, 
near  the  insertion  of  the  deltoid,  but  it  ran  down  to  some 
extent  even  into  the  hand,  and  it  was  increased  by  lying  on 
the  affected  side  and  by  changes  of  weather. 

There  was  marked  tenderness  at  a  point  in  front  of  the 
shoulder  joint,  near  the  coracoid  process,  and  also  at  the  back 
of  this  joint. 

Under  prolonged  massage  and  passive  motion  and  tonic 
treatment  a  considerable  degree  of  improvement  was  finally 
brought  about. 

XCVII. 

Weakness    of  the    Muscles    of   the    Forearm^    especially  the 

Extensors. 

Many  years  ago  I  was  called  to  see  a  man  who  had  been 
suffering  from  great  pain  and  weakness  of  the  arm,  for 
several  weeks. 

On  examination  I  found  all  the  muscles  of  the  forearm, 
both  flexors  and  extensors,  to  be  greatly  wasted,  although 
there  was  no  paralysis,  and  only  such  weakness  as  would  be 
explained  by  the  loss  of  muscular  tissue.  Besides  this  he 
had  the  signs  of  an  acute  inflammation  of  the  wrist  joint, 
which  was  swelled  and  excessively  tender. 


I20 


XCVIII. 

Di^ttse,  Progressive  Muscular  Weakness,  with  Trophic  Changes. 

This  patient  is  a  man  thirty-seven  years  of  age.  He  was 
always  well  until  thirteen  years  old,  and  was  as  strong  as 
any  of  his  companions  in  their  games.  At  the  age  of 
thirteen  he  began  to  have  stinging  pains  in  the  back  of  the 
neck  and  shoulder-blades  and  felt  a  loss  of  power  in  the 
shoulder  on  lifting  heavy  objects.  He  also  noticed  that  his 
scapulae  became  prominent  when  he  raised  his  arms  at  the 
shoulder.  He  could  whistle  and  use  the  lips  well  till  fifteen, 
but  then  they  began  to  grow  weak.  At  eighteen  the  extensor 
muscles  of  the  right  hand  became  weak.  At  thirty  the  right 
leg  began  to  drag  on  account  of  v/eakness. 

He  has  never  noticed  any  extreme  weakness  of  the  back 
muscles,  though  the  back  often  becomes  tired  from  long 
sitting,  and  it  is  difficult  for  him  to  rise  from  a  recumbent 
position.  There  has  been  a  tendency  to  toe-drop  for  six  or 
seven  years.  For  the  past  year  or  two  the  eyes  have  felt 
"weak."  The  vision  seems  all  right,  but  it  tires  him  to 
look  at  anything  for  a  long  time,  and  occasionally  there  is 
diplopia  for  a  moment.  He  kept  at  his  occupation  of  lasting 
shoes  until  thirty  years  old,  and  could  do  a  regular  day's 
work  in  spite  of  his  muscular  defects.  Since  then  he  has 
supported  himself  by  lighter  work,  chiefly  canvassing.  He 
used  to  drink  heavily  at  times,  but  never  had  any  sort  of 
venereal  disease. 

Physical  Examination. —  There  is  a  marked  asymmetry  of 
the  face  and  head,  the  chief  feature  being  a  bulging  in  the 
region  of  the  right  temple,  while  there  is  a  distinct  flatten- 
ing of  the  skull  over  the  outer  part  of  the  left  eyebrow. 
The  ears  are  rather  lacking  in  convolutions  and  not  of  ex- 
actly the  same  shape.  The  face  is  almost  devoid  of  ex- 
pression, all  the  muscles  being  wasted.  The  movements  of 
the  frontalis  muscle  are  weak  and  deficient,  especially  on 
the  left.  The  eyelids  close  feebly,  and  can  be  opened  with 
the  finger  very  easily,  against  the  patient's  will 


Case  XCVIII. 


Case  XCVIII. 


Case  similar  to  XCVIII. 


121 


The  movements  of  the  eyes  are  normal,  but,  when  they 
are  turned  strongly  to  one  side,  twitching  movements  are 
seen.  All  the  lower  facial  muscles  are  weak ;  the  lips  are 
thin ;  the  corners  of  the  mouth  can  be  drawn  up  or  down 
hardly  at  all;  whistUng  is  impossible.  In  the  standing 
position  there  is  marked  lordosis;  and  the  head  is  thrust 
forward  so  that  the  lower  cervical  and  upper  dorsal  verte- 
brae are  very  prominent,  as  if  from  Pott's  disease,  this 
appearance  being  increased  by  the  atrophy  of  the  tra- 
pezius muscles.  The  shoulders  droop  much,  and  can  only 
be  feebly  and  imperfectly  raised. 

The  scapulae  stand  out  from  the  spine,  and  the  lower 
angles  nearly  meet  when  the  arms  are  extended.  The 
rhomboids  and  latissimus  dorsi  are  much  atrophied. 
The  posterior  muscles  of  the  neck  (except  the  trapezius) 
are  fairly  well  preserved.  There  is  no  fibrillary  twitching 
to  be  seen  anywhere. 

The  deltoids  are  very  large  and  abnormally  firm,  even 
when  at  rest;  and  the  same  condition  is  present  in  the 
supra  and  infra  spinatus  muscles.  The  muscles  of  the  back 
are  feeble  and  apparently  atrophic.  All  motions  of  the  legs 
are  preserved  but  are  very  weak,  especially  those  of  the 
thigh  muscles,  but  the  only  movement  which  is  wholly  lost 
is  dorsal  flexion  of  the  foot. 

The  forearm  muscles  are  relatively  well  preserved.  The 
biceps  and  triceps  of  both  arms  are  small  and  weak,  flexion 
at  the  elbow  being  almost  impossible,  though  partially  per- 
formed by  the  brachiahs  anticus.  In  walking,  the  feet  are 
lifted  high  to  clear  the  toe  from  the  ground,  and  thrown  for- 
ward {steppage).     The  knee-jerks  are  Hvely  and  equal. 


122 


XCIX. 


IVide-spread  and  Progressive  Muscular  Weakness^  with  Nutri- 
iiofial  Muscular  Changes,  in  a  Boy  of  Ten.  Older 
Brother  similarly  affected. 

In  the  month  of  February,  1901,  two  small  boys,  thirteen 
and  ten  years  old,  were  brought  to  the  hospital  for  advice, 
their  parents,  who  were  Russian  Jews,  having  transported 
them  hither  all  the  way  from  Texas  in  the  hope  of  relief. 

It  is  the  younger  boy  whose  picture  is  given  ;  but  the  con- 
dition of  his  older  brother  was  similar  to  his,  only  worse,  so 
that  he  was  unable  to  stand  alone. 

The  history  given  was  also  substantially  the  same  in  both 
cases.  Their  own  story  was  that  they  had  been  well  until 
the  onset  of  the  disease,  which  had  attacked  the  older 
brother  two  years  ago,  the  younger  within  only  five  months. 

The  symptoms  had  come  on,  they  said,  very  suddenly. 
One  of  the  boys  declared  that  he  was  walking  along  and 
feeling  all  right,  when  his  back  gave  way  so  that  he  could 
only  hold  himself  erect  by  throwing  the  abdomen  forward 
and  shoulders  back.  Now  the  older  brother  is  so  feeble 
that  he  has  to  be  carried  in  arms,  while  the  younger  still 
walks,  but  with  great  difficulty  and  with  a  waddling  gait. 
The  trunk  is  in  a  position  of  marked  lordosis.  The  arms 
are  extremely  feeble,  as  well  as  the  legs,  and,  when  they  are 
raised  from  the  shoulder,  the  scapulae  stand  off  from  the 
chest  and  almost  touch  each  other  behind. 

The  diagnosis  can  easily  be  made  with  the  aid  of  this 
description  and  by  an  examination  of  the  photographs. 
The  students  are  especially  requested  to  notice  the  contours 
of  the  muscular  masses,  in  order  to  detect  the  signs  of  other 
changes  beside  those  of  an  atrophic  character. 

It  may  be  said  that  certain  of  the  muscles  had  a  pecu- 
liarly  dense,  inelastic  feeling,  even  when  not  contracted. 


Case  XCIX. 


Case  C. 


123 


Paresis  of  the  External  and  Internal  Eye  Micscles^  Some 
Difficulty  iji  Use  of  Li^nbs. 

This  patient  is  a  man  of  forty-five.  The  chief  thing  seen, 
when  one  looks  at  him,  is  that  whether  walking  or  sitting,  he 
carries  his  head  constantly  turned  to  the  left.  Otherwise,  he 
looks  fairly  well,  although  rather  thin  and  pale.  When  one 
looks  at  him  more  closely,  it  is  seen  that  the  facial  muscles 
twitch  here  and  there  in  small  bundles.  This  is  more 
marked  on  the  right  side  than  on  the  left,  and  is  most  no- 
ticeable over  the  forehead  and  about  the  lips  and  chin. 
The  man  is  a  clerk,  and  says  that  he  had  gonorrhoea  ten 
years  ago,  but  no  "  sores,"  to  his  knowledge.  Six  or  seven 
years  ago  he  began  to  have  cramps  in  the  calves  of  the 
legs  at  night,  and  since  then  the  legs  have  been  growing 
weaker,  though  not  to  a  high  degree.  Three  years  ago  he 
found  it  difficult  to  read  his  newspaper,  and  so  went  to  an 
oculist,  and  then  first  discovered  that  although  he  could  move 
his  eyes  to  the  right,  he  could  not  move  them  to  the  left. 
It  was  then,  too,  that  the  position  of  the  head  was  first 
pointed  out  to  him.  It  had  gradually  been  assumed  with- 
out his  really  being  aware  of  it. 

For  the  past  couple  of  years  he  has  had  severe  pain  in 
the  right  arm  from  time  to  time,  just  above  the  elbow,  some- 
times by  day,  sometimes  by  night ;  and  five  weeks  ago  this 
became  so  bad  that  he  went  to  the  Massachusetts  Hospital 
for  advice.  At  the  same  time,  also,  he  began  to  have  pains 
in  the  left  occipito-parietal  region.  He  says  his  hands  be- 
come numb  at  times,  if  the  arms  lie  long-  in  one  position. 
Possibly  some  light  is  thrown  on  the  cause  of  the  pain  in 
the  arm  by  the  fact  that  the  movements  are  restricted 
at  the  shoulder,  and  that  if  carried  out  by  force  severe 
pain  is  felt  in  the  upper  arm.  When  he  walks,  he  goes 
so  unsteadily  people  think  him  drunk,  though,  in  fact, 
he  does  not  take  liquor  at  all. 


124 

Not  only  is  the  head  turned  to  the  left,  but  it  trembles, 
though  with  so  fine  a  motion  that  close  examination  is  re- 
quired to  notice  it,  and,  when  the  muscles  of  the  neck  and 
back  are  examined,  fine  fibrillary  contractions  are  seen  to 
play  over  the  surface,  similar  to  those  seen  about  the  face. 
The  right  pupil  is  slightly  larger  than  the  left ;  and  neither 
of  them  reacts  either  to  light  or  with  accommodation.  He 
can  close  both  eyelids,  but  the  right  one  so  feebly  that  but 
very  little  force  is  required  to  raise  it  against  his  effort. 
Both  eyes  turn  strongly  to  the  right,  and  the  left  cannot  be 
turned  back  again.  The  fundus  of  the  eyes  is  normal. 
There  is  no  change  in  the  speech.  There  is  slight  atrophy 
in  the  supra-scapular  muscles  on  the  right  side.  The 
muscles  of  the  limbs  are  not  remarkably  atrophied. 

The  knee-jerks  and  the  wrist-jerks  are  both  exaggerated. 
Ankle-clonus  is  present  on  the  left  side,  and  the  Babinski 
reflex  also.  His  memor}?^,  he  says,  is  failing,  and  his  sleep 
is  disturbed  by  pain.  He  has  been  under  observation  for 
some  months  without  material  changes  having  been  seen. 

CI. 

Severe  Headache^  with  Paralysis  of  Certain  Eye  Muscles. 

In  October,  190 1,  a  Syrian  of  middle  age  applied  for  re- 
lief of  throbbing  headache,  which  had  been  troubling  him 
for  three  months.  This  was  located  in  the  left  supra-orbi|;al 
region,  and  extended  over  the  top  of  the  head  to  the  occi- 
put. It  had  been  almost  constant,  but  was  especially  severe 
at  night,  so  that  he  could  not  sleep  without  the  use  of  seda- 
tives. Lying  with  his  head  resting  on  the  left  side  in- 
creased the  pain.  He  had  been  unable  to  attend  to  his/ 
occupation  of  silk-weaving  since  the  trouble  began. 

During  the  past  two  weeks  there  had  been  drooping  of 
the  left  eyelid,  and  double  vision  on  looking  toward  the 
ri^ht.  The  vision  was  thought  to  be  growing  poorer. 
There  had  been  no  nausea  nor  vomiting.     The  patient  did 


I2S 

not  use  alcohol  in  excess ;  but  he  had  contracted  gonorrhoea 
twice,  six  months  and  three  years  previously.  There  was  xxo 
history  of  syphilis. 

Examination  showed  marked  ptosis  of  the  left  eyelid, 
while  the  pupil  on  that  side  was  considerably  dilated  and 
failed  to  react  to  li^ht  or  with  accommodation.  The  right 
pupil  was  of  medium  size,  and  reacted  normally. 

On  testing  the  movements  of  the  eyes,  it  was  found  that 
there  was  almost  no^ower  in  the  left  internal,  supmor  and 
inferior  recti  muscles.  The  fundus  was  normal.  There 
was  no  marked  tenderness  on  pressure  over  the  left  supra- 
orbital foramen.  There  was  no  disturbance  of  sensation  of 
the  face  nor  paralysis  of  the  facial  muscles.  The  tongue 
was  clean,  and  protruded  in  the  median  Hne.  The  knee-( 
jerks  were  normal. 

The  patient  was  given  iodide  of  potassium  in  rapidly 
increasing  doses,  but  for  the  first  few  nights  morphia  was 
required  before  sleep  could  be  obtained.  After  a  week  of 
treatment  by  iodide,  the  headache  had  disappeared,  but  it 
was  six  weeks  before  the  ptosis  was  overcome,  and  then 
there  was  still  dilatation  and  rigidity  of  the  pupil  and  paresis 
of  the  affected  muscles. 

CII. 

Progressive  Difficulty  in   Talking  and  Stv allowing ;  eventually 
Some  Involvement  of  Limbs. 

A  business  man  of  sixty-six,  with  an  excellent  record  of 
health  and  habits  and  a  good  family  history,  complained 
that  for  the  past  two  months  —  as  the  result  of  a  severe 
cold,  he  thought  —  he  had  had  a  difficulty  in  talking,  and  to 
some  degree  in  swallowing  liquids.  The  saliva  had  also 
collected  in  his  mouth  of  late.  Before  the  onset  of  these 
symptoms  he  had  been  perfectly  well,  he  said ;  but  he  was 
a  man  of  cheerful  temper,  and  incHned  to  make  hght  of  his 
troubles,  and  his  son  testified  that  he  had  noticed  some  dis- 
turbance of  both  speech  and  hearing  for  six  months  back. 


126 

Now,  the  voice  has  become  monotonous  and  nasal  in 
quality,  the  enunciation  of  some  sounds  is  very  imperfect, 
and  an  occasional  syllable  or  short  word  is  slurred  (as 
"once  a  while"  for  "once  in  a  while").  When  he  gets 
laughing  or  tries  to  talk  rapidly  he  often  has  a  fit  of  strang- 
ling and  choking. 

The  tongue  was  found  unnaturally  smooth^  flabby,  moist, 
and  lacking  in  freedom  of  motion,  and  fibrillary  tremors 
played  over  it. 

At  the  first  examination  the  wrist-jerks  and  knee-jerks  were 
not  abnormal ;  but  a  few  months  later  the  knee-jerks  were  H-, 
and  the  right  wrist-jerk  was  greater  than  the  left.  As  the 
case  progressed,  the  hands  and  feet  became  "  numb  "  and 
weak,  the  speech  less  and  less  distinct,  and  finally  unintel- 
ligible. Choking  at  table  became  alarmingly  frequent  and 
serious,  and  he  died  in  about  nine  months. 

Intelligence,  hopefulness,  and  cheerfulness  were  preserved 
to  the  last. 

It  should  be  said  that  the  radial  arteries  were  tortuous 
and  atheromatous,  but  that  the  heart  and  kidneys  were 
essentially  healthy. 

cm. 

Difficulty  in  Speech  and  Swallowing^  and  to  Some  Extent 
in  the   Use  of  the  Extremities ;   Congenital. 

This  patient  was  a  young  woman  of  twenty,  and  the  ap- 
pearance that  she  presented  when  first  seen  was  a  very 
striking  one.  It  was  evident,  at  the  first  glance,  that  there 
was  something  wrong  with  her  face;  although,  beyond  the 
fact  that  she  had  an  unusually  high  color  and  a  rather 
eager  look  about  the  eyes,  and  that  her  mouth  was  held 
pj,rtly  open  even  when  she  was  at  rest,  nothing  especially 
remarkable  was  to  be  seen.  The  moment  she  began  to 
speak,  however,  the  trouble  declared  itself.  She  was  prac-i 
I  tically  talking  without  the  use  of  her  tongue,  and  with  an 
imperfect  use  of  the  lips,  so  that  there  were  some  sounds] 


t0f^ 


(M     *. 


12/ 

which  it  was  impossible  to  distinguish  except  by  guess. 
Her  mother  said  that  she  was  born  with  this  defect,  and 
that  until  she  was  ten  years  old  it  was  with  difficulty  that 
she  could  be  understood  at  all,  so  that  her  school  life  had 
been  largely  ruined.  When  she  was  an  infant,  attempts  at 
swallowing  would  sometimes  almost  strangle  her,  so  that  her 
mother  would  take  her  to  the  window  for  the  reviving  effect 
of  the  air.  Furthermore,  until  she  was  seven  or  eight  years 
old  the  saliva  used  to  run  out  of  the  niouth,  so  that  her 
clothes  were  constantly  wet  to  the  waist.  Even  now  there 
is  a  great  deal  of  difficulty  in  masticating  and  shallowing 
her  food,  and  liquids  sometimes  come^t^ck  through  the 
nos^,  although;  so  far  as  can  be  judged  of  by  the  finger,  the 
masseter  and  temporal  muscles  contract  pretty  firmly,  the 
left  not  quite  so  well,  however,  as  the  right.  She  cannot 
p_ur^  her  lips  for  whistling ;  and  as  for  the  tongue,  although 
she  can  put  it  out  in  a  straight  line  fairly  well  for  a  moderate 
distance,  she  cannot  move  it  either  ujD_and  down,  or  sidewise 
in  the  least  degree.  The  palate  moves  but  slightly  with 
phonation.  When  she  tries  to  spg^k,  she  makes  so  strong 
an  effort  that  the  accessory  muscles  of  the  neck  come  in 
play,  especially  the  platysma. 

Her  difficulties  are  not  confined  to  the  muscles  of  speech 
and  swallowing.  Both  hands  are  weak ;  and,  when  she  tries 
to  straighten  the  fingers,  they  remain  somewhat  crooked, 
especially  the  two  smaller  ones.  This  is  much  more  true  of 
the  left-hand  than  of  the  right.  So,  too,  the  motions  of  the 
left  leg  are  not  quite  so  free  as  those  of  the  right ;  and  her 
left  foot  is  apt  to  turn  in  walking.  The  knee-jerks  are  both ' 
very  sjiglit,  and  the  left  is  greater  than  the  right.  The 
sensibility  of  the  skin  is  everywhere  perfect.  When  asked 
about  her  eyes,  she  said  that  use  of  them  made  them  ache^ 
and  that  the  lower  lid  of  the  right  eye  twitched  a  great 
deal.     Otherwise  they  were  normal. 

An  electrical  examination  showed  that  the  muscles  most 
involved  reacted  less  vigorously  to  local  stimulation,  whether 


128 

with  galvanism  or  faradism,  than  those  which  were  better 
preserved,  but  there  was  nowhere  any  sign  of  degenerative 
reaction. 

An  electrical  treatment  was  instituted  for  the  stimulation 
of  the  nerves  of  the  muscles  of  the  tongue  and  lips,  and 
with  this  exercises  in  speech  were  given ;  but  she  made  no 
further  progress  than  such  as  might  be  attributed  to  encour- 
agement and  increased  effort. 

There  had  never  been  a  case  just  like  this  in  the  patient's 
family ;  but  her  mother  was  neuropathic  in  temperament,  and, 
out  of  four  brothers,  three  died  young  with  acute  diseases. 
The  father  and  one  brother  and  some  members  of  the 
father's  family  had  died  of  tuberculosis,  and  one  sister  had 
had  epilepsy. 

CIV. 

Attacks  of  Weakness  of  All  the  Muscles  of  the  Body,  ending 

fatally. 

[Case  Reported  by  Dr.  W.  E.  Paul.] 

A  woman  twenty-three  years  old  had  been  subject  to  spells 
of  faintness,  occurring  in  the  morning,  during  which  she  felt 
as  if  she  must  lie  down  and  sleep,  but  she  never  lost  con- 
sciousness in  them. 

These  attacks  began  when  she  was  sixteen,  and  prevented 
her  from  going  to  school.  They  never  troubled  her  after 
her  marriage,  w^hich  took  place  when  she  was  twenty.  A 
year  and  a  half  from  the  time  she  was  married  she  gave 
birth  to  a  healthy  child.  The  labor  was  normal,  and  the 
puerperium  uneventful.  The  child  was  not  nursed  by  its 
mother. 

Eight  months  before  presenting  herself  at  the  hospital,  and 
eighteen  months  after  her  confinement,  while  taking  the  part 
of  a  Japanese  girl  in  private  theatricals,  she  stooped  low,  in 
a  line  with  a  number  of  other  performers.  At  a  given  cue  all 
the  line  were  to  resume  the  standing  attitude  ;  but  the  patient 


129 

could  not  rise,  and  asked  for  help.  She  was  ridiculed  a  bit, 
and  then  assisted  to  stand.  In  the  final  performance  she 
received  assistance  from  her  comrades  on  either  side,  and 
suffered  no  further  disability.  Next,  ascending  stairs  be- 
came difficult.  In  boarding  a  car,  she  could  not  lift  her  feet 
without  assistance.  If  merely  helped  in  the  usual  way  by 
taking  her  hand  or  arm,  she  would  be  pulled  forward  and 
fall  on  her  face.  This  loss  of.  muscular  power  was  of  brief 
duration.  Crossing  the  knees  at  times  required  assistance. 
She  could  usually  walk  on  a  level,  but  stepping  up  was  fre- 
quently difficult.  In  spite  of  her  symptoms  she  attended  to 
her  housekeeping  and  cared  for  her  baby. 

Examination  (eight  months   after  the  first  symptoms). 

The  patient  was  of  medium  size  and  well  nourished ;  calm 
and  rather  indifferent  in  manner.     Her  color  was  good,  but 
the  blood  was  not  investigated.     No  marked  weakness  of 
voluntary  muscles  appeared  at  the  time  of  examination.     The 
gait  was  normal.     She  could  raise  either  foot  to  a  chair  seat, 
but  required  some  slight  assistance  to  mount  the  chair.     The 
grasp  and  various  movements  of  the  fingers  and  arms  were 
made  easily,  with  apparent   normal  strength.     She  talked, 
swallowed  water,  and  used  her  ocular  and  facial  muscles 
with  no  sign  of  paresis.     Objectively,  no  change  in  sensibility 
to  touch  or  pain  could  be  discovered.    No  tenderness  existed 
over  the  muscles  or  nerves.     Vision  and  hearing  were  undis- 
turbed, and  the  fundus  was  normal.    The  visual  field  was  not 
Hmited,  and  there  was  no  diplopia.     Romberg's  symptom 
was  absent.    The  knee-jerks  were  both  normal.     No  attempt 
was  made  to  tire  this  reflex.    The  pupils  were  equal,  and  re- 
acted to  light  and  accommodation.     The  urine  had  a  sp.  gr. 
of  T.014,  and  showed  a  trace  of  albumen. 

Transient  weakness  in  the  arms  next  appeared.  At  times 
they  would  drop  like  lead,  without  sensory  disturbance.  Her 
husband  had  to  support  them  when  she  arranged  her  hair. 
To  insert  a  hat  pin,  she  rested  the  elbows  on  the  mantel.  In 
playing  the  piano,  both  hands  tired  easily.    She  would  some- 


I30 

times  have  to  drag  the  baby  to  her  lap  rather  than  Uft  him 
clear.  Once,  when  attempting  to  take  him  from  his  crib,  it 
was  impossible  to  straighten  up  until  assisted.  She  refrained 
from  handling  fragile  objects.  There  was  difficulty  at  times 
in  buttoning,  and  ability  to  do  millinery  and  embroidery  was 
lessened.  The  attacks  of  weakness  became  more  frequent. 
These  symptoms  were  of  short  duration,  and  came  on  usually 
after  severe  use  of  those  muscles  in  which  weakness  or  com- 
plete loss  of  power  developed.  She  not  infrequently  fell 
backwards  on  the  stairs ;  and  on  one  occasion,  when  near  the 
top,  the  legs  gave  way,  and  she  fell  with  the  baby  in  her  arms, 
sliding  down  several  steps  without  injury.  Transient  diplopia 
occurred  in  the  course  of  the  disease,  and  it  was  noticed  at 
times  that,  when  she  looked  up,  the  head  was  thrown  back 
indicating  ptosis.  The  muscles  of  mastication  escaped. 
There  was  lack  of  expression  in  the  face,  and  the  laugh 
seemed  incomplete.  The  voice  at  times  was  nasal  and  some- 
what indistinct,  though  not  lowered.  Words  were  correctly 
chosen,  and  speech  was  never  really  lost.  One  day  the  words 
ran  together  and  the  lips  seemed  powerless,  but  holding  the 
upper  lip  with  the  fingers  obviated  her  difficulty.  Swallow- 
ing was  sometimes  awkward,  and  in  the  later  stages  this 
difficulty  became  serious.  The  neck  muscles  sometimes  sud- 
denly gave  way,  so  that  the  head  required  support. 

The  symptoms  became  more  frequent,  and  involved  on 
several  occasions  very  nearly  all  of  the  voluntary  muscular 
system.  One  evening  six  months  before  death,  after  climb- 
ing the  stairs  safely,  she  fell  to  the  floor  unable  to  move  or 
speak,  but  finally  succeeded  in  attracting  attention  by  tapping 
the  floor  with  her  heel.  Later,  in  attempting  one  day  to 
step  up  on  the  piazza,  she  fell  in  a  heap,  and  had  to  be 
carried  bodily  into  the  house.  In  a  third  instance,  five 
weeks  before  death,  she  fell  helpless  at  the  top  of  the  stairs. 
After  a  few  moments  she  regained  control  of  her  muscles  in 
each  instance.  Some  drowsiness  followed  the  last  attack,  but 
no  unconsciousness. 


131 

The  most  serious  symptom  to  develop  was  choking,  the 
first  attack  occurring  about  six  months  before  death.  At 
the  commencement  of  a  meal,  the  first  attempt  to  swallow 
water  caused  strangulation.  She  became  cyanosed  and  un- 
conscious, but  revived  at  the  end  of  about  thirty  minutes. 
A  month  later,  after  taking  two  swallows  of  water  without 
trouble,  the  third  choked  her.  Cyanosis  and  unconscious- 
ness followed,  and  tracheotomy  was  seriously  considered. 
Such  attacks  and  the  accompanying  apprehension  impaired 
nutrition  materially,  but  there  was  no  local  atrophy.  Her 
mind  remained  clear.  Palpitation  and  dyspnoea  occurred, 
but  were  not  prominent  symptoms. 

There  was  no  numbness  nor  prickling.  Appetite  and  diges- 
tion were  good.  The  disposition  was  unaltered.  The  cata- 
menia  reappeared  after  confinement,  and  did  not  modify 
the  symptoms.  The  sphincters  were  unaffected.  There  was 
no  spasmodic  movement,  stiffness,  nor  tenderness.  Emotional 
excitement  aggravated  the  disturbance. 

During  the  last  few  months  of  life  the  attacks  of  weak- 
ness became  more  frequent  and  profound ;  yet,  when  seen  in 
the  intervals,  she  gave  no  impression  of  serious  illness.  The 
bulbar  symptoms  became  more  pronounced,  and  at  one  time 
rectal  feeding  was  practised  ;  but  the  ability  to  swallow  food 
and  liquids  returned  while  at  the  Boston  City  Hospital, 
some  months  before  death.  Toward  the  end  she  was  some- 
times unable  to  roll  over  or  to  sit  up  in  bed,  showing  in- 
volvement of  trunk  muscles. 

The  ocular  symptoms  also  increased,  but  there  were  remis- 
sions with  apparent  normal  muscular  balance.  Exposure  to 
cold  did  not  aggravate  the  condition,  as  a  rule ;  but  once, 
on  leaving  the  cars  after  a  journey,  she  became  helpless  on 
encountering  the  chill  of  a  March  air.  Three  days  before 
death  she  was  able  to  try  on  a  dress,  and  two  days  before 
death  she  sat  in  a  chair  and  swallowed  without  trouble.  At 
this  time  she  complained  of  palpitation,  and  of  a  sharp  pain 
in  the  right  iHac  region.     The  lungs  filled  up,  but  became 


132 

clear  again  after  several  hours  There  was  no  temporary  in- 
ability to  spit  out  or  swallow  the  secretions.  Death  occurred 
eighteen  months  after  the  first  symptoms. 

Autopsy  revealed  macroscopically  nothing  pathological  in 
the  nervous  system  or  the  musculature. 

CV. 

Sudden  Attack  of  Severe  Dizziness  with  Pain  in  the  Face 
and  To7igue ;  Facial  Palsy ^  and  Paralysis  of  Certain 
Eye  Muscles. 

The  patient  was  a  lady  of  fifty,  with  good  health  up  to 
the  time  of  onset  of  the  present  illness,  which  occurred 
as  follows :  While  she  was  bathing  herself,  after  rising  in 
the  morning,  she  suddenly  felt  an  intense  pain  of  stinging 
character,  at  the  left  edge  of  the  tongue  near  the  tip,  and 
likewise  in  the  face  near  the  angle  of  the  mouth.  At  the 
same  time  she  felt  herself  intensely  dizzy  and  nauseated. 
Surrounding  objects  seemed  to  reel  about,  and  it  was  with 
difficulty  that  she  could  get  to  the  door  and  call  for  help, 
severe  vomiting  attending  this  effort.  Consciousness  was 
not  disturbed.  The  pain  soon  spread  to  the  left  ear  and 
left  side  of  the  head,  then  over  the  whole  forehead  and 
eyes ;  and  this  pain  remained  all  day.  Vomiting  also  oc- 
curred at  intervals  through  the  day,  and  likewise  dizziness, 
the  latter  being  increased  by  any  motion  of  the  head  or  by 
turning  in  bed.  She  had  double  vision,  and  all  the  objects 
in  the  room  looked  unnatural,  so  that  she  was  obliged  to 
keep  her  eyes  covered. 

On  examination  it  was  found  that  she  had  complete 
paralysis  of  the  lower  facial  muscles  and  incomplete  paraly- 
sis of  the  forehead  and  eyelids  on  the  left  side.  Neither 
eye  could  be  completely  opened.  The  motions  of  the  eye- 
balls were  incomplete,  especially  those  of  the  left  side,  and 
this  defect  particularly  concerned  the  movements  of  abduc- 
tion  of   the  left  eye,  so  that  she  had  a  slight  strabismus. 


133 

The  left  pupil  was  smaller  than  the  right,  and  did  not  re- 
spond either  to  light  or  with  accommodation.  The  lower 
jaw  was  displaced  about  one-quarter  of  an  inch  to  the  left 
side,  and  swallowing  was  defective.  The  sensibility  of  the 
left  side  of  the  face  was  impaired.  When  she  attempted  to 
walk  she  staggered  badly,  generally  toward  the  left,  though 
there  was  no  impairment  of  motion  or  disturbance  of  sensi- 
bility of  either  the  arms  or  legs. 

As  time  went  on,  she  improved  very  slowly  in  some  re- 
spects ;  but  by  the  end  of  a  week  or  ten  days  faradic  irrita- 
bility of  the  left  facial  nerve  was  found  to  be  lost,  while 
degenerative  reactions  were  present  to  galvanic  excitation, 
the  positive  pole  exciting  stronger  contractions  than  the  neg- 
ative. This  "  reaction  of  degeneration  '^  was  more  marked 
for  the  lower  facial  muscles  than  for  the  upper.  Exami- 
nation of  the  heart  and  urine  revealed  nothing  abnormal. 

The  patient  lived  for  thirteen  years  after  this  attack,  and 
was  in  fairly  good  health,  though  she  always  retained  sHght 
traces  of  the  conditions  above  described.  She  was  a  per- 
son of  somewhat  nervous  temperament,  but  free  from  any 
well-marked  stigmata  of  disease. 

CVI. 

Intense  Headache ;    Increasing  Stupor;  Irregular  Convulsive 
Movements  of  All  Extremities^  of  Slight  Degree :  Death. 

A  man  somewhat  past  middle  age,  but  considered  to  be  in 
excellent  health,  a  teacher  by  profession,  came  home  one 
day  after  a  fatiguing  mentaLeffort,  complaining  of  intense, 
diffuse  headache.  He  sat  with  his  head  resting  on  his 
hands  for  a  time,  and  then  went  to  bed,  but  soon  became 
dull  and  finally  unconscious.  He  still  moved  about  rather 
restlessly  in  bed,  and  twitching  m<^^^^"^^T'tiS  were  visible  in 
both  hjLjids  and  arms,  but  of  slight  amount.  It  was  consid- 
ered probable,  on  account  of  the  headache  and  the  gradual 
increasing  stupor  without  localizing  symptoms,  that  he  was 


134 

suffering  from  meningeal  hemorrhage,  although  no  sufficient 
cause  for  this  could  be  discovered. 

An  operation  was  accordingly  advised,  and  it  was  de- 
cided to  trephine  on  the  left  side,  inasmuch  as  the  greatest 
amount  of  convulsive  movement  and  paralysis  seemed  to  be 
on  the  right,  although,  in  fact,  there  was  no  very  great  differ- 
ence between  the  two  sides  in  this  respect.  At  the  opera- 
tion nothing  was  discovered  except  that  the  convolutions 
were  flat  and  rather  dry  on  the  surface.  The  patient  died 
on  the  following  day,  and  examination  showed  that  the  hem- 
orrhage was  on  the  opposite  side,  where  it  covered  the  en- 
tire hemisphere. 

CVII. 

Convulsions  of  the  Right  Arm  and  Leg  and  Right  Side  of  the 
Face^  leading  to  Hemiplegia^  with  Involvement  of  the  Arm 
much  mo7'e  than  the  Leg. 

A  lady  of  forty,  who  proved  to  have  diabetes,  from  which 
she  died  five  or  six  years  later,  was  attacked  with  clonic  con- 
vulsion of  the  left  hand  and  left  side  of  the  face,  and  to  a 
slight  extent,  of  the  left  leg.  This  lasted  for  ten  or  fifteen 
minutes,  and  then  disappeared  for  a  time,  to  return  later. 
After  it  was  over,  the  speech  was  found  imperfect,  and  the 
motions  of  the  left  hand  and  arm  were  very  much  impaired, 
though  not  wholly  lost.  The  motions  of  the  leg  were  but 
slightly  affected.  The  leg  soon  began  to  improve,  but  she 
never  regained  the  finer  motions  of  the  fingers.  She  could 
walk  fairly  well,  though  not  without  awkwardness  of  the  left 
leg.  The  speech  disorder  soon  passed  away.  For  a  time 
she  remained  subject  to  recurrences  of  slight  convulsions  of 
the  hands,  not  attended  by  unconsciousness ;  but  for  a  num- 
ber of  years  before  her  death  she  had  no  recurrences. 

The  history  of  the  case  in  other  respects  may  be  passed 
over,  but  it  is  important  to  know  that  at  the  autopsy  a  lesion 
was  found  in  the  anterior  transverse  convolution,  about  mid- 
way   betsveen    the  fissure  of    Sylvius    and    the  longitudinal 


135 


> 


n 
< 


136 

fissure,  which  might  be  described  as  a  slight  degree  of 
porencephalus.  The  change  was  not  so  great  as  to  attract 
much  attention  on  casual  observation ;  but,  in  fact,  it  was 
found  that  the  convolutions  at  this  point  had  caved  in,  over  a 
small  area,  and  that  the  pia  mater  was  thick  and  adherent  to 
the  cortex.  Furthermore,  on  cross  section  the  whole  corona 
radiata  at  that  point  was  found  to  be  much  narrower  than  at 
the  corresponding  part  of  the  opposite  hemisphere.  This 
narrowing  of  the  white  substance  was  much  more  extensive 
than  the  size  of  the  lesion  of  the  cortex  would  have  sug- 
gested. 

CVIII. 

Injury  to  the  Head,  followed  by  Headache,  Vomiting,  gradu- 
ally deepening  Impairment  of  Consciousness,  Convulsions  : 
Eventual  Recovery, 

A  boy,  ten  years  old,  fell  and  struck  his  head  on  the  ice 
while  skating.  There  was  no  loss  of  consciousness,  and  he 
got  up  at  once  and  went  to  school,  but  was  sent  home  be- 
cause he  acted  "foolish."  He  stayed  in  bed  most  of  the 
time  during  the  following  two  days,  complaining  of  headache 
and  general  malaise.  When  spoken  to  he  seemed  stupid, 
and  his  answers  were  irrelevant. 

Early  on  the  morning  of  the  third  day  he  began  to  vomit, 
and  during  the  day  he  had  two  or  three  convulsions,  and 
gradually  lapsed  into  a  state  of  unconsciousness.  That 
night,  the  convulsions  seeming  to  come  at  shorter  intervals, 
he  was  taken  to  the  hospital. 

When  seen  in  the  accident-room,  his  temperature  was 
101°  F. ;  the  pulse-rate,  98;  respiration,  25,  and  noisy. 
Though  apparently  unconscious,  he  would  put  his  hand  to 
his  head  when  asked  if  he  had  any  pain,  but  no  answers 
could  be  elicited  by  questioning.  There  was  no  evidence  of 
external  injury  of  the  head.  There  was  conjugate  deviation 
of  the  eyes  toward  the  left.  The  pupils  were  equal,  though 
widely  dilated,  and  reacted  slightly  to  light.     No  paralysis 


137 

of  the  extremities  could  be  made  out.  The  deep  and  super- 
ficial reflexes  were  lively,  and  the  Babinski  phenomenon  was 
present  on  both  sides. 

During  the  subsequent  twelve  hours  the  convulsions  came 
with  more  or  less  regularity,  every  half-hour,  sometimes 
starting  in  the  face,  sometimes  in  the  left  arm  or  leg,  and 
quickly  becoming  general.  Each  attack  lasted  three  to  four 
minutes.  The  attacks  always  terminated  in  his  opening  the 
jaws  widely  and  snapping  them  together,  a  number  of  times. 
During  the  latter  part  of  the  fourth  day  the  intervals  between 
the  attacks  began  to  lengthen,  and  the  convulsions  became 
shorter,  at  times  only  involving  the  face  and  neck.  On  the 
fifth  day  the  convulsions  ceased ;  and  he  would  answer  ques- 
tions rationally,  but  in  the  manner  of  one  talking  in  his 
sleep.  There  were  no  more  convulsive  attacks  during  his 
convalescence  ;  and  he  woke  up  on  the  morning  of  the  sixth 
day  in  apparently  clear  mental  condition.  He  had  no  recol- 
lections of  the  events  which  had  occurred  since  his  accident, 
the  last  thing  he  could  remember  being  that  he  was  skating. 
The  subsequent  convalescence  was  uneventful. 

CIX. 

Hemiplegia  of  Unusual  Form  and  Onset. 

An  unmarried  lady,  seventy-three  years  old,  had  a  mild 
attack  of  "grippe  "  with  slight  bronchitis,  and  pleurisy  with 
effusion,  about  the  middle  of  January.  Two  weeks  later, 
while  sitting  up  in  bed  and  taking  her  breakfast,  she  sud- 
denly felt  a  numbness  and  helplessness  of  the  left  hand  and 
arm,  so  great  that  she  could  scarcely  raise  her  arm  from  the 
table.  There  was  no  affection  of  consciousness,  nor  any 
weakness  of  the  leg  or  face,  but  there  was  a  distinct  sensory 
as  well  as  motor  affection  of  the  hand,  so  that,  while  it  lasted, 
she  could  not  tell  what  she  held  in  her  fingers.  After  a  brief 
time  this  condition  passed  away,  or  nearly  so  ;  but  about  a 
fortnight  later,  while  she  was  taking  her  supper,  she  seemed 


138 

suddenly  to  doze  off,  and  did  not  respond  to  questions. 
The  muscles  of  the  jaw  and  left  arm  became  rigid.  For  a 
few  moments  her  breathing  seemed  to  be  checked,  but  pres- 
ently it  came  back  with  a  gasp.  When  she  came  to  herself, 
she  was  much  excited,  but  had  no  knowledge  of  what  had 
happened.  It  was,  however,  found  that  the  movements  of 
the  left  arm  and  hand  were  highly  ataxic,  the  speech  thick, 
and  the  left  leg  very  weak.  The  sense  of  position  of  the 
left  arm  was  so  much  affected  that  she  could  not  tell,  without 
looking,  whether  her  hand  was  on  the  table  or  under  it,  nor 
could  she  use  it  for  feeding  herself  or  holding  objects, 
though  there  was  but  little  actual  paralysis  of  motion.  The 
sensibility  of  the  skin  as  regards  temperature  and  pain  was 
greatly  impaired,  so  that  at  one  time  she  burned  herself 
without  knowing  it. 

The  hand  also  felt  numb  and  prickly,  but  was  not  so  pain- 
ful as  the  foot,  where  she  suffered  greatly  from  a  sense  of 
cold  and  aching,  and  later  from  burning  and  stinging,  as  if 
from  the  bite  of  a  venomous  insect.  All  the  motions  of  the 
leg  and  foot  were  possible,  yet,  when  she  tried  to  use  the  leg, 
it  would  give  way  at  the  knee.  Her  speech  was  not  really 
aphasic,  and  the  slight  awkwardness  in  enunciation  soon 
passed  away.  Her  memory  became  slightly  impaired,  and 
has  not  been  fully  recovered. 

At  the  time  of  my  examination  all  movements  of  the  left 
hand  were  possible,  though  feeble  and  imperfect;  but  the 
fingers  were  extended  at  the  phalangeal  joints,  and  any 
attempt  to  flex  them  caused  pain.  Passive  movements  at 
the  shoulder  also  caused  pain,  and  all  the  joints  of  the  left 
hand  and  arm  were  tender  on  deep  pressure.  The  sensibility 
of  the  skin  and  the  sense  of  position  of  the  fingers  were  still 
somewhat  impaired,  though  much  less  so,  she  said,  than  at 
first.  All  movements  of  the  left  foot  were  also  possible  ;  but 
the  foot,  ankle,  and  leg  were  swelled,  hot,  and  tender.  Here 
also  there  was  moderate  impairment  of  sensibility  of  all 
modes.     The  knee-jerks  were    but    little  altered,  though  it 


139 

was  said  that  they  had  been  increased.  The  Babinski  reflex 
could  not  be  obtained  in  a  typical  form.  Hemianopsia  was 
not  present.  The  patient  talked  clearly  and  intelligently. 
On  examination  of  the  heart  a  systoHc  murmur  was  heard  at 
the  left  edge  of  the  sternum,  and  the  attending  physician 
said  that  at  times  a  well-marked  systoHc  murmur  had  been 
heard  at  the  apex.     The  beat  of  the  heart  was  very  irregular. 

ex. 

Wide-spread  Paralysis  with  Unconsciousness,  following  an 
Acute  Infectious  Disease.  Partial  Recovery;  Mental 
Deterioration. 

A  healthy  boy,  thirteen  years  old,  of  neuropathic  family, 
passed  through  a  moderate  attack  of  mumps,  in  November, 
1895.  Ten  days  later  he  woke  up  feehng  poorly  and  with 
convergent  strabismus  of  the  right  eye.  The  next  morning 
he  had  a  partial  ptosis  of  both  eyehds,  and  slight  deafness. 
He  also  complained  of  intense  pain  in  the  forehead,  and 
became  very  dull  and  drowsy.  The  temperature  was  not 
taken  at  first,  but  two  days  later  it  was  found  to  be  100°  F. 
During  the  next  week  all  the  symptoms  grew  worse,  and 
slight  delirium  came  on.  All  four  Hmbs  became  weak  and 
numb.  The  temperature  did  not  range  very  high,  but  there 
was  continuous  slight  fever.  When  examined  by  me,  a 
few  days  after  the  onset  of  the  illness,  there  was  almost  com- 
plete deafness,  bi-lateral  ptosis,  bi-lateral  facial  paresis, 
double  optic  neuritis,  paralysis  of  the  external  eye  muscles, 
and  irridoplegia  with  myosis.  Consciousness  was  greatly 
impaired,  and  the  knee-jerks  and  wrist-jerks  were  absent  on 
both  sides.  In  spite  of  these  serious  symptoms  he  began  to 
improve  after  a  few  days,  and  finally  recovered  substantially, 
but  retained  traces  of  optic  neuritis,  strabismus,  impaired 
vision,  and  impaired  hearing  for  a  number  of  months,  and 
became  subject,  in  addition,  to  epileptiform  seizures.  Six 
months  later  these  disorders  had  nearly  disappeared  ;  but  his 


140 

character  was  found  to  have  become  altered,  so  that  he  was 
unreliable  and  mischievous,  and  from  this  tendency  he  has 
never  recovered.  After  many  futile  attempts  to  set  him  up 
in  business,  he  was  pronounced  incurable  and  sent  to  an 
institution. 

CXI. 

Temporary  Paralysis  of  Arms  and  Legs,  of  Acute  Onsets  with 
Disturbance  of  Sensibility.  Improvement^  followed  by 
Headache  a7id  Convulsion.     Recovery. 

A  middle-aged  man,  of  good  previous  health  and  good 
habits,  was  exposed  on  two  successive  days,  during  Novem- 
ber, in  a  rain-storm.  The  next  day  he  found  the  right  foot 
and  leg  weak,  and  shortly  afterward  the  left ;  and  this  weak- 
ness increased  so  rapidly  that  at  the  end  of  a  few  hours  he 
was  scarcely  able  to  get  upstairs.  The  left  foot  felt  slightly 
numb,  and  later  became  the  seat  of  burning  sensations.  The 
next  day  he  was  worse,  and  the  hands  and  arms  had  become 
more  or  less  involved  in  the  same  manner.  The  pain  and 
soreness  was  increased  by  deep  pressure  of  the  forearms  and 
calves,  that  in  the  arms  being  most  severe  along  the  ulnar 
border.  There  was  no  burning  sensation  in  the  hands  as 
there  had  been  in  the  feet,  but  only  lack  of  strength.  When 
he  tried  to  wind  the  clock,  the  fingers  refused  to  hold  the  key. 
Micturition  was  normal,  but  increased  in  frequency.  He 
never  became  so  weak  that  he  was  unable  to  walk ;  but  this 
cost  him  a  great  effort,  and  he  sometimes  fell  heavily  to  the 
ground  when  his  knees  became  bent  a  little  out  of  the  per- 
pendicular. After  about  a  week  he  began  to  improve  slowly, 
the  sense  of  burning  heat  being  the  first  symptom  to  pass 
away.  Up  to  this  time  there  had  been  no  disturbance  of  the 
cranial  nerve  systems  and  no  affection  of  breathing  nor 
swallowing.  After  the  improvement  had  progressed  to  a 
certain  point,  however,  he  began  to  have  headache,  which 
seemed  to  have  been  first  excited  by  one  of  his  falls.  The 
pain  began  in  the  back  of  the  head,  but  was  felt  eventually 


141 

in  various  parts,  and  continued  in  greater  or  less  intensity 
for  several  weeks.  Finally,  one  day,  just  a  month  after  the 
onset  of  the  first  symptom,  and  while  still  suffering  from  the 
headache,  he  had  a  sudden  attack  of  prickly  sensation  in  the 
right  leg  and  immediately  afterward  in  the  right  arm,  from 
the  knee  to  the  foot  and  from  the  elbow  to  the  hand  respec- 
tively. This  passed  away  in  half  an  hour,  but  the  next  day 
he  had  a  severe  convulsion  which  lasted  two  hours.  He 
was  seen  by  me  two  days  after  this,  and  was  found  to  have  a 
rectal  temperature  of  ioi°,  and  very  severe  headache.  The 
tenderness  of  the  limbs  was  no  longer  present.  Ophthal- 
moscopic examination  showed  no  distinct  neuritis,  but  an 
appearance  as  if  of  a  slight,  diffuse  oedema  of  the  retina. 

A  letter  received  from  the  patient  six  weeks  later  reported 
that  he  had  improved,  but  was  still  weak  and  was  unable  to 
walk  much,  and  that  he  was  suffering  from  double  vision. 
The  calves  of  the  legs  still  felt  sore  at  times.  By  the  end  of 
another  year  he  had  substantially  recovered. 

CXII. 

Acute,  Severe  Headache  in  a  Young  Person,  followed  by 
Unconsciousness  without  Further  Symptoms,  and  ending 
fatally, 

A  young  married  lady,  who  was  of  an  excitable  nervous 
temperament,  although  intelligent  and  self-controlled,  and 
who  had  been  a  great  sufferer  from  severe  headaches,  was 
attacked  with  intense  pain  in  the  head  on  the  second  day 
after  the  birth  of  her  first  child.  There  was  a  moderate  rise 
of  temperature,  but  no  other  bad  symptoms,  either  local  or 
general;  and  the  attack  was  at  first  thought  to  be  of  the 
familiar  kind.  Gradually,  however,  in  the  course  of  twenty- 
four  hours,  although  the  headache  somewhat  abated,  she 
passed  into  a  condition  in  which  she  lay  quite  still,  not  ap- 
pearing to  suffer  pain,  but  taking  no  notice  of  what  went  on 
around  her.     At  first  she  could  be  aroused  in  a  measure  by 


142 

questions ;  and,  when  this  was  no  longer  the  case,  a  sharp 
pricking  would  make  her  frown  and  raise  her  hand  as  if  the 
pain  was  felt  somewhat,  after  which  she  would  at  once  re- 
lapse again  into  the  same  condition  as  before.  Respiration 
was  not  stertorous,  nor  apparently  altered  in  any  way. 
There  was  not  much  change  noticed  in  the  appearance  of 
the  face.  The  pupils  varied  in  size,  sometimes  growing 
larger,  sometimes  smaller,  without  much  regard  to  the 
strength  of  the  light.  The  question  arose  as  to  whether  her 
condition  was  one  of  hysterial  stupor  or  of  some  more  seri- 
ous trouble.  The  former  conclusion  was  favored  at  first ; 
but,  in  fact,  a  general  convulsion  came  on  the  next  day  but 
one,  immediately  after  which  she  died.  The  diagnosis  and 
post-mortem  findings  will  be  brought  out  in  the  discussion 
of  the  case. 

CXIII. 

Headache ;  Pallor^  without  Discoverable  Changes  in  the  Blood. 

Imagine  yourself  called  to  see  a  young  married  woman 
of  twenty-eight,  complaining  of  general  exhaustion  and  in- 
ability to  concentrate  her  thoughts,  and  of  constant  head- 
aches, frontal  and  occipital.  You  notice  that  she  looks 
very  white,  but  find  on  examination  that  the  haemoglobin  is 
present  to  the  amount  of  90  per  cent,  and  that  the  red 
globules  number  fully  five  million.  You  talk  with  her,  and 
get  the  following  history. 

She  was  always  of  excitable,  "  high-strung "  tempera- 
ment, but  used  to  consider  herself  pretty  well.  During 
her  childhood  her  domestic  conditions  were  very  unhappy, 
so  that  while  at  home  she  was  under  a  constant  strain. 
Her  conditions  in  this  respect  were  improved  by  a  happy 
marriage  when  she  was  about  twenty  years  old.  But  her 
new  responsibilities  brought  new  fatigue.  Even  as  a  child, 
she  used  to  have  a  great  deal  of  headache  ;  and  for  many 
years  she  has  scarcely  been  free  from  it.  Now  the  pains 
are  quite  intense  at  times,  and  keep  her  awake  at  night. 


f^     [^Zytyi      U-r-^^     ■*^^«*^  ^r^   ^MM-^ 


143 

At  other  times  she  drops  to  sleep,  in  spite  of  the  pain, 
though  she  generally  wakes  tired  and  uncomfortable.  There 
is  no  disorder  of  the  menstrual  functions  nor  any  uterine 
displacement. 

On  examination  of  the  eyes  slight  errors  of  refraction  were 
found,  of  which  astigmatism  was  one ;  but  prolonged  treat- 
ment with  glasses  proved  of  little  benefit. 

The  nose  was  next  examined ;  and  a  hypertrophy  of  the 
middle  turbinate  was  discovered,  which,  it  was  thought, 
might  cause  obstruction  of  the  ducts  leading  from  the 
ethmoid  sinus.  (This  thickening  was  due  to  a  peculiar 
porosity  of  the  turbinate  bones  associated  with  enlarge- 
ment and  swelling.)  The  turbinate  was  removed  under 
ether,  and  for  a  time,  after  the  soreness  had  passed  away, 
she  seemed  to  be  a  little  better ;  but,  again,  the  improve- 
ment was  not  permanent. 

In  spite  of  the  condition  of  the  blood  as  shown  by  tests, 
a  prolonged  course  of  iron  was  advised.  Strychnia  in  large 
and  increasing  doses  was  also  given,  and  at  the  same  time 
a  thorough,  tonic  water-treatment  was  instituted  and  static 
electricity  was  used  for  a  long  period.  Under  this  and 
similar  tonic  measures  there  was  a  gradual  improvement  in 
the  course  of  a  year,  though  the  headache  by  no  means 
ceased 

CXIV. 

Headache. 

A  gentleman  of  fifty-five  was  seized  with  an  intense  froutaJ 
headache,  so  that  he  called  a,  physician  near  by  in  the  middle 
of  the  night,  who  relieved  him  with  a  little  morphine.  This 
headache  was  not  a  new  thing  with  him,for  he  had  suffered 
from  it  for  a  dozen  years,  though  it  had  never  been  sojexere 
as  now.  He  was  a  delicate  man,  a  clergyman  by  profession, 
and  a  hard  worker,  and  had  great  responsibilities  in  a  large 
parish.  The  physician  went  away,  but  returned  early  in  the 
morning  and  found  him  still  suffering  greatly,  but  exhibiting 
no  other  symptoms,  and  showing  n£i„evidence  of  fever. 


144 

While  he  was  sitting  by  his  side,  the  patient's  head  and 
\  eyes  suddenly  turned  strongly  to  the  left,  the  muscles  of  the 
I  whole  body  became  rigid  and  tremulous,  and  consciousness 
'was  completely  lost.  This  condition  lasted  for  perhaps  two 
minutes,  at  the  end  of  which  time  the  patient  ffreatly  recov- 
ered  himself,  and  showed  no  memory'  of  what  had  passed. 
It  became  obviously  important  to  discover  the  cause  of  this 
dizziness,  and  to  learn  whether  it  was  related  to  the  severe 
headache  of  the  previous  night  or  to  the  long  standing 
tendency  to  pain  in  the  head.  It  was  learned  that  the  eyes 
had  been  repeatedly  and  carefully  examined  for  errors  of 
refraction,  but  another  examination  was  made  with  a  view 
to  ascertain  whether  optic  neuritis  was  present,  ^^othijig, 
however,  was  discovered.  The  urine  was  next  examined, 
and  this  examination  was  repeated  frequently  through  the 
course  of  the  next  few  days,  but,  beyond  the  discovery  of 
minute  traces  of  albumen  and  a  few  hyaline  and  finely 
granular  casts,  nothing  abnormal  was  found.  He  had  had 
more  or  less  nasal  catarrh  for  a  long  time ;  but  this  was  not 
especially  troublesome,  and  there  was  no  evidence  of  any 
permanent  obstruction. 

Physical  examination  as  regards  abdominal  and  thoracic 
organs  was  wholly  negative,  and  the  reflexes  were  normal. 

Applications  of  cold  to  the  head,  prolonged  tepid  baths, 
laxatives,  complete  rest,  and  other  measures  were  instituted, 
with  only  temporary  relief.  The  second  examination  of  the 
eyes  showed  only  that  one  border  of  the  rip;ht  di&k  was  dis- 
tinctly hazy.  The  subsequent  history  will  be  given  in  the 
course  of  the  discussion. 

CXV. 

Very  Gradual  Loss  of  Consciousness^  with  Pain  in  the  Head, 
followi?ig  a  Slight  Injury.     Eventual  Recovery. 

A  gentleman  of  seventy,  of  strong  will,  though  naturally 
of  delicate  health,  had  a  slight  fall  from  his  carriage  on 
account  of  the  breaking  of  an  axle.     He  struck  his  head  a 


0^     ^^^ 


^)^Ji4,.n^  ILmaJ^ 


145 

moderate  blow ;   and  this  was  followed  by  a  slight  and  per- 
sistent  headache,    which  very  gradually  increased    in    the 
course  of  the  next  week.     At  first  it  did  not  incapacitate 
him  for  talking  and  enjoying  himself,  however,  though,  as 
a  matter  of   prudence,    he    stayed    in    bed.     Gradually   he 
^egan  to  grow  duller,  and  by  the  end  of  the  week  he  had 
become  apathetic    and    stupid    almost  to  complete  uncon- 
sciousness, so  that  his  discharges  were  passed  involuntarily 
injied.     There  was  no  resjlessness,  no  fever,  no  delirium. 
He  simply   lay   there   motjonless,   looking   very  pale,   and 
scarcely  to  be  roused.     After  this  condition  had  continued 
for   some  days,  improvement  gradually  set  in.     This  was 
even  more  gradual  than  the   onset ;  but  by  the    end  of  a 
month  he  was  almost  completely  restored  to  health,  though 
somewhat  weak  and  languid  for  a  good  while  longer. 

CXVI. 

Headache. 

In  April,  1895,  an  intelligent  law  student  of  twenty-five 
came  for  relief  on  account  of  extremely  annoying  frontal 
headache.     He  was  an  intelligent   man,  but  looked  worn 
and  depressed,   though  entirely  freg  from  distinct  morbid 
ideas.     This   headache  had  already  pursued  him  for   two 
years,  coming  on  more  or  less  every  day,  and  it  continued 
to  trouble  him  for  several  years  after  the  first  examination. 
Study  or  mental  activity  made  it  worse,  and  a  trip  into  the 
country  made  it  temporarily  better.     Besides  this,  his  head 
felt  confused  and  dull,  and  every  task  was  an  effort  to  him, 
even  those  which  he  enjoyed.     He  was  not  subject  to  nasal 
catarrh ;   and,  although  he  had  certain  errors  of  refraction, ' 
including  astigmatism,  these  had  been  corrected  so  far  as  ■ 
possible  by  several  oculists,   but  without  securing  him   the 
least  relief. 

The  personal  history  and  family  history  were  of   some 
interest.     He    had    been   subject,    in    his   youth,  to  "sjck 


146 

headaches" ;  and  both  his  parents  and  his  brothers  had 
shown  the  same  tendency.  (He  was  not  a  good  sleeper,  and 
suffered  from  unpleasant  dreams."'  Occasionally  he  would 
have  three  or  four  emissions  on  successive  nights,  and  then 
none  for  a  long  time,  but  he  did  not  think  his  head  was 
\ worse  for  these.  As  a  boy,  he  was  "sensitive"  in  disposi- 
tion, and  worried  about  trifles,  and,  although  he  had  grown 
more  philosophical,  yet  the  same  general  tendency  per- 
sisted. 

Examination  of  the  heart  showed  nothing  abnormal,  and 
the  pulse  was  not  tense.  The  knee-jerks  were  exaggerated. 
Various  measures  were  devised,  tending  to  improve  the 
general  vigor,  and  with  some  success  ;  but  the  headache 
persisted,  and  it  became  a  question  whether  he  should  keep 
on  with  his  study  of  the  law  or  take  up  some  less  exacting 
occupation.  Finally,  he  was  advised  to  disregard  the  head- 
ache altogether,  and  to  act  just  as  if  he  did  not  have  it, 
except  for  taking  reasonable  precaution  in  regard  to  his 
general  health.  This  treatment  was  followed  eventually  by 
marked  improvement,  so  that  he  has  been  able  to  carry  on 
active  business  and  has  enjoyed  increasing  vigor. 

CXVII. 

Persistent  Occipital  Headache. 

A  tall,  slender  girl,  twenty-eight  years  old,  and  delicate  in 
appearance,  had  been  left  in  straightened  circumstances, 
and  obliged  to  work  for  her  living.  During  the  past  five 
years  her  mother,  sister,  and  two  brothers  have  all  died  of 
pulmonary  tuberculosis. 

She  has  always  had  more  or  less  occipital  headache,  but 
during  the  past  five  years  it  has  been  much  more  constant 
and  severe.  For  several  months  it  has  troubled  her  so 
much  that  she  has  spent  all  her  money  in  trying  to  get,. re-, 
lief,  having  been  to  four  eye  specialists  and  tried  several 
varieties  of  glasses.     She  has  been  unable  to  work  for  two 


^XMfJ^i^iA'UM/JMi 


147 

months ;  and  her  friends  say  that  her  expression  is  much 
changed,  and  that  she  looks  as  if  she  wanted  to  gry  gut.  with 
the  pain  all  the  time. 

The  headache  is  never  accompanied  with  disturbance  of 
vision,  and  there  is  no  vomiting.  It  never  keeps  her 
awake. 

The  patient  says  that  she  did  not  begin  tojrienstruate 
until  she  was  eighteen,  and  that  for  the  past  two  years  the 
catamenia  are  always  accompanied  by  diarrhoea  with  eight 
or  ten  watery  movements  a  day.  This  diarrhoea  lasts  four 
or  five  days,  and  is  followed  by  a  spell  of  obstinate 
constipation. 

After  a  systematic  course  of  treatment  of  a  wholly  differ- 
ent sort,  the  old  occipital  headaches  disappeared,  though 
there  is  still  slight  frontal  headache  during  the  period  of 
menstruation. 

CXVIII. 

Injury  with  Unconsciousness  ;  Improvement^  then  Relapse  ; 
Fever  aiid  Muscular  Rigidity :  Death. 

A  middle-aged  man  was  brought  to  the  hospital  partially 
unconscious,  and  with  the  history  that  he  had  a  violent  fall 
several  hours  before. 

On  examination,  a  scalp  wound  was  found  on  the  back  of 
the  head  and  a  contusion  of  the  left  frontal  region.  No 
fracture  could  be  made  out.  There  were  signs  of  slight 
bleeding  at  the  nose.  The  pupils  were  normal,  but  a  slight 
degree  of  external  strabismus  was  present.  The  pulse  was 
60,  and  the  temperature  100°  F. 

The  next  day  the  patient  was  conscious,  but  was  some- 
what dull  and  not  rational.  The  dejections  and  micturition 
occurred  involuntarily.  During  the  first  week  the  mental 
condition  improved  steadily,  but  after  that  no  further  im- 
provement took  place,  and  the  patient  remained  for  weeks 
longer  dull  and  slow  in  mind,  with  uncertain  memory  and 
not  quite  clear  as  to  his  surroundings. 


148 

At  the  end  of  the  first  week  a  painful  stiffness  of  the 
neck  came  on  with  retraction  of  the  head ;  and  the  tempera- 
ture, pulse,  and  respiration  rose  notably  (130°,  103.5,  ^^^ 
30,  respectively). 

On  the  twelfth  day  the  left  leg  and  thigh  became  tender 
to  pressure ;  and  after  that  the  pain  and  stiffness  of  the  neck 
increased,  and  respiration  grew  more  and  more  labored  and 
finally  purely  diaphragmatic,  and  the  pulse  and  temperature 
increased.  On  the  seventeenth  day  the  patient  died,  the 
temperature,  pulse,  and  respiration  having  risen  rapidly 
toward  the  last  to  105°  F.,  190,  and  70,  respectively. 

An  account  of  the  post-mortem  examination  will  be  given 
in  connection  with  the  discussion  of  the  case. 

CXIX. 

Convulsions  of  the  Left  Side,  recurring  regularly  in  an  Elderly 
Patient  recovering  from  Lijfuenza,  and  resulting  in  Hemi- 
plegia. 
A  lady  of  seventy  had  a  typical  attack  of  the  "  grippe  " 
during  the  severe  epidemic  of  1892.  While  she  was  con- 
valescent, and  at  the  moment  actually  sitting  up  in  her  chair 
knitting,  her  left  arm  began  to  twitch  with  regular  clonic 
movements  of  flexion  and  extension.  These  movements 
soon  ceased,  but  in  twenty  minutes  they  returned  again ;  and 
this  time  the  leg  also  was  involved  to  some  degree.  At  the 
end  of  another  twenty  minutes  a  third  attack  came  on,  in 
which  the  face  was  affected  as  well.  Consciousness  was 
not  lost  on  either  occasion.  In  this  fashion  it  went  on 
through  the  day,  attacks  of  the  sort  described  returning  and 
then  passing  away.  After  a  time,  however,  recovery  was 
not  complete ;  and  finally  a  condition  of  paralysis  of  the 
entire  left  side  developed,  and  the  following  day  she  sank 
away  and  died.  At  the  autopsy  the  brain  was  found  ex- 
tremely oedematous  and  very  pale.  A  minute  examination 
of  all  parts  failed,  however,  to  reveal  any  lesion.     At  the 


149 

microscopic  examination  venous  or  capillary  stasis  was  dis- 
covered here  and  there,  but  no  sign  of  inflammatory 
chan jjes  or  special  lesions  of  any  kind. 

CXX. 

Attacks,  at  Differefit  Periods,  of  Transient  Hemiplegia  with 
Aphasia;  Paraplegia  with  Crossed  Paralysis  of  Sensa- 
tio?i,  Motion^  etc.     Improvement  under  Treatment. 

In  October,  1883,  I  was  called  to  see  a  gentleman  thirty- 
five  years  old,  unmarried,  on  account  of  rapidly  iiicreasing 
loss  of  pfiLEgr  in  the  le^,  especially  in  the  left.  I  found 
him  in  his  chair  and  unable  to  rise.  The  right  leg  was,  to 
be  sure,  freely  movable  at  all  the  joints,  and  showed  fair 
strength ;  but  the  left  was  almost  wholly  paralyzed.  He 
could  not  move  the  foot  and  toes  at  all,  but  could  flex  the 
leg  very  slightly  at  the  knee  and  could  make  a  few  move- 
ments at  the  hip.  On  attempts  to  extend  the  left  leg  at  the 
knee  a  strong  extensor  spasm  occurred,  while  under  other 
circumstances  flexor  spasms  came  on.  Examination  of  the 
sensibility  showed  a  marked  dhninution  of  the  sensitiveness 
to  touch  and  pricking  over  the  entire  right  leg  and  thigh, 
but  a  hypersesthesia  over  the  leftjeg  and  the  lower  part  of 
the  abdomen.  He  complained  also  of  a  disagreeable  sense 
of  burning  all  over  the  trunk,  especially  on  the  left_side. 
This  was  most  marked  at  the  level  of  the  nipple,  and  was  so 
great  that  he  could  not  bear  to  be  touched,  and  could  not 
lie  on  his  left  side.  The  sphincters  were  not  wholly  under 
the  patifintis-coatijol.  The  knee-jerks  were  exaggerated  on 
both  sides,  especially  on  the  left ;  and  ankle-clonus  was 
present  in  coiX£spondijig  degree. 

I  learned  on  inquiry  that,  five  months  previously,  on  wak- 
ing in  the  morning,  he  had  been  unable  to  walk  straight  or 
to  control  properly  the  movements  of  his  left  hand.  He  was 
also  unable  to  arti^late_distinctly,  so  that  it  was  with  diffi- 
culty that  he    made  himself   understood.     He  rapidly  im- 


ISO 

\proved,  however,  in  all  these  respects,  and  by  afternoon 
was  entirely  well,  except  that  the  left  hand  felt  a  little  awk- 
ward. Three  months  later,  after  having  felt  poorly  for  two 
weeks,  he  was  suddenly  attacked  with  severe^p^in  in  the 
abdomen,  with  nausea  and  vomiting,  then  with  very  severe 
pain  up  and  down  the  back.  This  pain  was  supposed  to 
be  rheumatic,  and  was  attributed  to  exposure  to  wet  on  his 
sail-boat.  A  few  days  later  he  began  to  lose  strength  in  the 
left  leg :  and  the  symptoms  above  noted  came  on,  with,  at 
first,  ret^tion  of  the  urine. 

Under  appropriate  treatment  the  patient  gradually  im- 
proved, so  that  he  can  now  walk  about  slowly,  though  the 
motions  of  the  left  leg  have  never  become  normal.  Three 
years  later,  after  having  felt  poorly  for  a  time,  he  became 
confused,  aphasic,  and  drowsy.  The  right  side  of  the 
face  became  slightly  paralyzed,  but  the  right  hand  and  leg 
were  not  affected.  The  mental  dulness  amounted  almost 
to  a  stupor.  After  about  a  week,  however,  he  began  to  im- 
prove, under  treatment,  though  he  remained  for  some  time 
confused  and  indifferent  to  passing  events,  and  was  troubled 
with  visual  hallucinations  or  illusions. 

On  another  occasion  he  had  a  brief  attack  of  momentary 
unconsciousness,  attended  by  strabismus.  In  spite  of  these 
severe  attacks  the  patient  finally  improved  still  further ;  and, 
except  for  the  paralysis  of  the  left  leg  and  a  certain  amount 
of  loss  of  sensibility  of  the  right  leg,  and  a  slight  impairment 
of  the  control  over  the  sphincters,  he  has  remained  well. 
Two  years  ago  he  was  attacked  with  cystitis  due,  appar- 
ently, to  a  vesical  calculus ;  and  from  this  he  has  never 
wholly  recovered. 

CXXI. 

Complete  Paralysis  of  Acute  Onset,  with  Universal  Rigidity. 

A  gentleman  of  seventy-five  was  heard  to  fall  heavily  to 
the  floor  in  his  study.  When  his  friends  reached  him,  he 
was  unconscious  and  breathing  heavily.     He   soon  became 


i5i 

stertorous,  the  face  covered  with  perspiratitn,  and  all  the 
extremities  rigid  and  tremulous.  From  time  to  time  a  spasm 
ran  through  all  the  muscles  of  the  body,  causing  an  increase 
of  rigidity  of  the  trunk  and  limbs.  Most  of  the  time  the 
arms  were  rotated  strongly  inward  and  the  hands  clenched. 
He  did  not  recover  consciousness,  and  died  in  a  few  hours, 

A  post-mortem  examination  showed  a  flattening  of  the 
cerebral  convolutions,  obviously  due  to  the  pressure  from 
an  enormous  hemorrhage  into  the  interior  of  the  brain, 
which  had  destroyed  a  good  portion  of  the  left  hemisphere, 
and  part  of  the  right.  The  basal  ganglia  were  also  partly 
destroyed,  and  the  ventricles  were  filled  with  blood. 

CXXII. 

Convulsive  Seiziwes ;    Attacks  of  Unconsciousness  with  Auto- 
matic MovemeJits. 

A  girl  twenty-nine  years  old  had  been  subject  to  attacks 
of  convulsions  ever  since  she  was  nine.  She  always  knew 
when  one  of  these  attacks  was  coming  on ;  for  they  were 
preceeded  by  a  sense  of  numbness  in  both  hands,  which 
gradually  extended  up  her  arms  till  it  reached  nearly  to  the 
elbows,  when  consciousness  was  lost.  Sometimes  she  had 
time  to  sit  down  before  she  lost  consciousness,  but  more 
often  she  fell  to  the  floor. 

Her  mother  said  the  fail  was  always  followed  by  a  marked 
cyanosis  and  a  general  rigidity  of  all  the  limbs,  and  this  by 
convulsive  movements  of  the  face  and  the  extremities, 
during  which  there  was  frothing  at  the  mouth,  the  froth  at 
times  being  bloody  from  bleeding  of  the  tongue,  which  was 
not  infrequently  bitten.  These  seizures  came  more  often 
in  the  day-time  than  at  night.  Each  one  lasted  two  or  three 
minutes,  and  was  followed  by  sleep. 

The  frequency  of  the  attacks  has  decreased  lately,  so 
that,  whereas  they  formerly  came  every  three  or  four  weeks, 
they  now  come  at  more  or  less  regular  intervals  of  two  to 


152 

three  months,  as  a  rule  occurring  at  the  time  of  menstrua- 
tion. 

Although  the  attacks  are  less  numerous  under  treatment, 
a  new  and  rather  distressing  feature  has  made  its  appear- 
ance during  the  past  few  years.  This  consists  of  "  spells  " 
of  the  following  nature,  which  come  over  her  without  any 
warning,  every  few  weeks  :  — 

While  talking  or  sitting  quietly,  her  face  becomes  suddenly 
blanched  and  her  eyes  open  widely,  and  stare  fixedly  into 
space.  This  lasts  but  a  moment,  and  she  then  begins  to 
undress  herself.  It  is  not  difficult  to  stop  her  from  this 
proceeding,  for  she  can  be  aroused  from  her  condition  of 
semi-consciousness ;  but,  when  allowed  to  go  on  as  she 
likes,  she  takes  off  her  clothes,  lies  down  and  goes  to  sleep. 

These  attacks  do  not  seem  to  be  affected  by  treatment. 

CXXIII. 

Attacks  of  Teniporary  Alte7-atio7i  of  Coftsciousness,    recurring 
repeatedly  m  the  Same  Form. 

A  middle-aged  man  has  been  subject  for  four  years  to 
spells  occurring  at  night,  at  the  onset  of  which  his  wife  is 
awakened  by  his  making  a  clucking  noise  in  his  throat.  On 
going  to  him,  she  finds  him  with  his  eyes  rolled  up  and  his 
face  pale,  looking  as  if  he  were  in  a  "dead  faint,"  and  is 
unable  to  arouse  him.  He  remains  in  this  condition  for  five 
or  ten  minutes,  and  then  goes  into  a  deep  sleep  for  two  to 
three  hours,  from  which  he  cannot  be  awakened.  On  re- 
covery from  these  attacks  he  gives  an  account  of  his  sensa- 
tions during  the  seizures  in  terms  like  the  following :  — 

He  suddenly  finds  himself,  he  says,  in  an  unknown  world, 
which  he  always  recognizes  as  having  been  visited  previ- 
ously. His  first  impression  in  his  new  surroundings  is  one 
of  pleasure  at  finding  himself  there  again.  He  finds  him- 
self standing  in  a  pathway  which  extends  through  beautiful 
tropical  vegetation,  more  beautiful  than  any  he  has  seen  on 


153 

earth.  The  air  is  soft  and  balmy,  and  the  gravel  walk  ex- 
tends through  the  garden  as  far  as  the  eye  can  reach ;  while 
from  some  distance  ahead,  and  always  from  the  right,  comes 
wonderful  music,  now  of  great  volume  and  now  dying  away 
to  the  sound  of  a  single  instrument,  soft  and  sweet  like  a 
flute,  but  so  marvellous  that  it  seems  as  if  it  must  be  played 
by  a  dozen  pairs  of  hands. 

At  his  left  there  always  stands  a  companion,  unlike 
earthly  beings,  about  five  feet  high.  There  are  no  features 
and  no  joints  to  his  limbs,  and  his  body  seems  covered  with 
a  grayish  fuzz.  The  patient  always  starts  at  the  same  place, 
and  walks  down  the  gravel  pathway,  which  crunches  un- 
pleasantly under  his  feet.  His  companion  glides  along  noise- 
lessly on  his  left,  and  he  constantly  exclaims  to  this  being 
of  the  beauty  of  the  clear  sky  and  the  surroundings.  When 
he  gets  to  a  certain  point  in  the  walk  and  is  approaching  the 
source  of  the  music,  there  is  a  sudden  change  in  the  scenery, 
and  he  finds  himself  in  the  doorway  of  a  large  room.  In 
the  foreground  is  an  engine  of  enormous  size,  while  in  the 
background  is  magnificent  machinery,  which  is  simple  in  its 
construction,  yet  so  wonderful  in  its  mechanism  that  he  al- 
ways wishes  he  had  paper  and  pencil,  that  he  might  make 
notes  to  show  afterward  to  his  friends.  His  peculiar  com- 
panion is  never  with  him  in  this  engine-room.  While  in  this 
state,  he  is  always  conscious  that  he  is  in  a  sort  of  a  dream. 
He  never  tastes  anything  nor  notices  any  fragrance  or  odors. 

The  attacks  are  always  precisely  the  same.  In  the  day- 
time these  attacks  will  come  while  he  is  at  work ;  and  his 
friends  say  that  he  stands  staring  into  space  for  two  or 
three  minutes,  first  making  a  clucking  sound  with  his  mouth. 
He  will  not  answer  when  spoken  to.  There  are  never  any 
convulsive  movements  during  these  attacks.  He  has  two  or 
three  of  them  in  a  month,  and  then  will  go  several  months 
without  any.  For  the  past  few  months  he  has  been  unable 
to  concentrate  his  thoughts  upon  anything,  and  is  absent- 
minded  and  forgets  many  essential  things  about  his  work. 
For  this  reason  he  has  been  discharged  from  his  position. 


154 

Several  months  after  the  above  history  was  taken,  the 
patient  was  found  in  the  street  one  day,  unconscious  and  in 
a  convulsion. 

CXXIV. 

Attacks  of  Unconsciousness  and  Convulsions. 

A  girl,  twenty  years  old,  had  lived  all  her  life  in  rather 
unhappy  surroundings,  she  being  quick-tempered  and  ex- 
citable, while  her  father  was  more  or  less  addicted  to  alcohol, 
and  inclined  to  be  brutal.  A  sister  had  died  of  eclampsia, 
and  a  brother  had  had  epilepsy  since  childhood. 

One  day  she  was  seized  with  a  convulsion  while  at  work 
in  the  factory  where  she  was  employed.  This  was  followed 
by  a  deep  sleep,  so  that  she  had  to  be  taken  home  in  an 
ambulance.  During  the  following  night  she  had  two  or 
three  similar  attacks,  in  one  of  which  she  bit  her  tongue  so 
that  it  bled.  When  seen  on  the  day  after,  she  complained  of 
severe  froPxtal  headache  and  abdominal  pain.  The  abdomen 
was  somewhat  tender,  though  there  was  no  muscular  rigidity. 
The  pupils  were  dilated,  but  responded  promptly  to  light. 
The  fundus  was  normal.  The  knee-jerks  were  lively  and 
equal.  Examination  of  the  urine  showed  nothing  abnormal. 
Although  it  was  impossible  to  obtain  any  description  of  the 
attacks,  she  was  put  on  moderately  large  doses  of 
bromide. 

A  few  nights  after  she  had  begun  treatment  she  was  walk- 
ing on  the  street,  when  she  suddenly  felt  dizzy  and  was 
overcome  by  a  stifling  sense  of  suffocation.  She  was,  how- 
ever, able  to  walk  to  the  house  of  a  friend  several  minutes 
distant ;  but,  after  reaching  the  door  and  ringing  the  bell, 
she  fell  down  in  a  "fit."  Her  friend  said  there  were  con- 
vulsive movements  for  a  few  minutes,  and  that  she  was  then 
unconscious  for  an  hour  and  a  half.  Several  days  later  she 
was  found  unconscious  in  the  street  and  taken  to  the  hospi- 
tal, where  she  remained,  with  no  recurrence  of  her  trouble, 
for  about  a  week.     While  in  the  hospital,  she  was  very  con- 


155 

tented,  and,  when  told  she  was  to  be  sent  out,  seemed  much 
upset,  and  a  few  minutes  after  was  heard  to  be  coughing 
violently.  On  going  to  her  bed,  she  was  found  unconscious, 
lying  on  her  back,  with  her  eyes  open  and  staring.  The 
pupils  were  widely  dilated,  but  responded  to  a  lighted  match. 
Her  body  was  in  a  state  of  tonic  spasm,  the  arms  extended 
at  her  side,  the  hands  clenched  and  grasping  the  bed- 
clothes. The  legs  were  straight,  and  the  toes  in  marked 
plantar  flexion.  There  was  no  visible  respiration,  and  the 
face  was  cyanotic.  Occasionally  there  would  be  a  gasp 
followed  by  a  short  paroxysm  of  coughing,  during  which  all 
the  muscles  relaxed  and  she  would  reach  out  and  grasp  the 
nurse's  dress  and  'pull  at  it  violently  (always  staring  fixedly 
straight  ahead),  and  then  relapse  into  a  state  of  rigidity 
again.  This  condition  lasted  twenty  minutes,  at  the  end  of 
which  time  she  regained  consciousness  and  began  to  cr}*. 
She  was  transferred  to  an  institution  better  adapted  for 
treatment  of  her  condition,  and  recovered  from  the  major 
attacks.  Once  or  twice  since  then  she  has  fallen  uncon- 
scious, but  has  immediately  recovered. 

cxxv. 

Epileptiform  Seizures  of  Peculiar  Character. 

A  single  woman,  fifty-one  years  old,  had  been  subject 
since  childhood  to  attacks  in  which  she  would  fall  without 
warning,  and  have  convulsive  movements  for  two  or  three 
minutes.  On  coming  out,  she  would  go  into  a  deep  sleep 
for  two  or  three  hours.  For  many  years  these  attacks  came 
on  with  more  or  less  regularity  every  six  or  eight  weeks. 
Besides  this  she  has  had  no  illness,  except  she  was  said  to 
have  some  ''  kidney  trouble  "  several  years  ago. 

Six  days  before  her  entrance  into  the  hospital  she  had  a 
convulsion,  apparently  of  the  character  of  her  usual  attacks ; 
but,  contrary  to  former  experience,  this  was  followed  by  a 
similar  seizure  the  following   day.     Then   she  felt   all  right 


156 

for  two  or  three  days,  though  her  brother  noticed  more 
or  less  mental  confusion.  Three  days  ago  she  had  a 
severe  convulsion  followed  by  delirium,  which  has  persisted 
ever  since. 

Physical  Examination. —  The  patient  lies  unconscious  in 
bed,  cyanotic,  and  with  stertorous  breathing.  Her  pupils 
are  equal,  and  react  normally.  The  heart  shows  enlarge- 
ment to  the  left.  The  sounds  are  rapid,  and  a  systolic 
murmur  is  heard  over  the  whole  precordial  region,  loudest 
at  the  pulmonic  area,  and  transmitted  into  the  axilla.  The 
pulmonic  second  is  not  accentuated  over  the  aortic.  The 
knee-jerks  and  plantar  reflexes  are  equal  and  not  exaggerated. 
Occasionally  the  right  arm  becomes  rigid  during  the  exam- 
ination. The  fundus  shows  no  optic  neuritis,  but  a  few 
retinal  hemorrhages  are  present. 

Examination  of  the  urine  shows  that  it  has  a  sp.  gr.  of  1007, 
is  pale,  acid,  and  with  half  a  per  cent,  of  albumen.  The 
amount  passed  in  twenty-four  hours  was  about  two  quarts, 
with  7  per  cent.  urea.  Careful  but  prolonged  search 
showed  a  very  rare  hyalin,  or  finely  granular  cast.  The 
temperature  within  the  next  few  days  ranged  between  99° 
and  100°  F.  The  pulse  was  about  100,  and  the  respiration 
20.  Unconsciousness  persisted,  and  incontinence  of  urine 
developed,  and,  finally,  swallowing  became  difficult,  and  the 
heart  grew  weaker.  Death  took  place  three  days  after  the 
above  examination. 

CXXVI. 

Periods  of  Unconscious7tess,  and  Other  Attacks  of  Peculiar  Sort. 

In  April,  1902,  a  woman  took  her  son,  a  bright-looking 
boy  of  seven  years,  to  a  physician  for  the  treatment  of  cer- 
tain peculiar  attacks  to  which  he  had  recently  become  sub- 
ject. She  said  that  last  August  he  began  to  have  spells  in 
which  he  would  fall  to  the  floor  and  lie  still,  with  the  eyes 
closed,  in  a  perfectly  relaxed  condition,  remaining  so  for  five 
or  ten  minutes.     There  were  no  convulsive  movements,  nor 


157 

was  there  involuntary  micturition  during  the  spells.  He 
had  four  or  five  of  these  attacks  at  intervals  of  one  to  three 
weeks.  Then  she  had  him  circumcised,  and  the  attacks  did 
not  recur  for  five  months,  after  which  time  they  returned 
with  as  great  frequency  as  before. 

Two  weeks  previously  to  her  visit,  while  the  boy  was  un- 
dressing one  night,  he  suddenly  uttered  a  scream,  followed 
by  a  queer-sounding  laugh,  and  started  to  run  across  the 
room.  He  was  caught  and  held  by  his  mother,  but  tugged 
and  pulled  to  get  away,  crying  out  that  *'  the  cats  were  after 
him,"  and  shouting,  "  I'll  kill  that  black  cat "  ;  "  Keep  them 
away,"  etc.  All  the  time  he  was  looking  wildly  around,  and 
his  face  had  a  queer  expression.  This  lasted  only  a  few 
minutes,  and  he  then  fell  into  a  deep  sleep.  Several  days 
later  he  had  a  similar  attack,  in  which  he  apparently  saw 
horses,  and  wanted  to  get  away  and  drive  them.  A  third 
attack  came  while  he  was  taking  a  walk  with  his  mother. 
On  this  occasion  he  began  screaming,  and  ran  across  the 
fields,  making  noises  like  the  yowling  of  cats.  It  was  sev- 
eral minutes  before  he  was  caught.  This,  too,  was  followed 
by  profound  sleep,  from  which  he  could  not  be  awakened  for 
several  hours. 

The  father  had  been  three  months  in  an  insane  hospital 
for  alcoholism  just  before  the  birth  of  the  child,  but  the 
family  history  was  otherwise  not  remarkable. 

CXXVII. 

Eccentric  and   Violent  Disposition;  Proloiiged  Unconsciousness, 
with  Temporcry  Paralysis  and  Altered  Reflexes :  Recovery. 

This  patient  is  a  large,  stout,  though  rather  pale  woman 
of  twenty-six  years,  who  has  always  been  of  a  neurotic  dis- 
position. Her  temper  is  uncontrollable,  and  her  husband 
says  that,  when  things  do  not  go  to  her  liking,  she  will 
stand  still  a  minute,  white  and  trembling  with  anger,  and 
then,  with  eyes  rolling  up,  she  will  fall  to  the  floor  in  a  fit. 


158 

thrashing  about  and  dashinq:  herself  against  the  furniture. 
These  paroxysms  often  last  five  or  ten  minutes.  Several 
times  she  has  seized  a  knife,  in  her  anger,  and  threatened 
to  kill  herself,  fighting  hard  against  her  husband  when  he 
tried  to  restrain  her. 

Two  weeks  previous  to  the  time  when  her  present 
trouble  began,  she  had  given  birth  to  her  second  child. 
There  had  been  considerable  loss  of  blood  during  the  labor, 
but  she  had  apparently  passed  through  the  puerperium  all 
right.  She  went  to  bed  one  night  feeling  perfectly  well, 
except  that  she  was  somewhat  upset  by  a  little  quarrel 
she  had  had  with  her  husband,  but  was  found  at  two 
o'clock  the  next  morning  in  a  convulsion,  which  lasted 
only  a  short  time  and  left  her  in  a  state  of  coma.  The 
unconsciousness  continued  through  the  night,  and  the  con- 
vulsions recurred  every  hour  with  great  regularity.  When 
seen  later  on  the  ensuing  day  she  was  lying  on  her  back 
with  the  face  and  eyes  turned  sharply  toward  the  left,  and 
in  a  condition  of  coma  from  which  she  could  not  be  roused. 
The  pupils  were  normal,  and  reacted  to  light.  There  was 
no  sign  of  paralysis  of  the  face  nor  extremities.  The  knee- 
jerks  were  exaggerated.  There  was  no  oedema  of  the  legs. 
The  heart  and  lungs  seemed  healthy.  During  the  examina- 
tion the  patient  was  seized  with  one  of  her  convulsive 
attacks.  It  began  with  a  rolling  up  of  the  eyes,  followed  by 
twitching  of  the  mouth  and  then  a  general  clonic  spasm  of 
the  extremities,  lasting  two  to  three  minutes.  This  gave 
place  to  a  condition  of  tonic  spasm  lasting  a  few  seconds, 
and  causing  marked  cyanosis  and  stertorous  breathing.  The 
blood  examination  showed  Hgb.  45  per  cent,  reds  4,000,000, 
whites  12,800.  The  urine  was  pale,  acid,  of  sp.  gr.  1021, 
and  contained  albumen  ^^  per  cent.;  urea  1.2  per  cent. 
Sugar  was  absent.  The  sediment  was  slight  in  amount, 
and  showed,  under  the  miscroscope,  a  few  hyaline  and  finely 
granular  casts. 

The  patient  was  given  a  hot-air  bath,  and  perspired  pro- 


^59 

fusely.  The  condition  remained  much  the  same,  however, 
during  the  next  twelve  hours,  except  that  the  conjugate 
deviation  disappeared  and  the  eyes  closed.  The  epilepti- 
form attacks  continued  to  come  every  hour,  and  between  them 
the  right  arm  remained  rigid  and  twitched  occasionally. 

On  the  second  day  the  left  arm  and  leg  were  perfectly 
limp  and  lay  still  as  if  paralyzed,  while  the  extremities  on 
the  other  side  were  kept  constantly  moving  about  the  bed. 
The  right  knee-jerk  was  absent,  and  the  left  slight.  A  pin- 
prick caused  the  drawing  away  of  the  right  arm,  but  was 
apparently  not  felt  on  the  left  side  at  all.  There  was  incon- 
tinence of  urine  and  faeces  ;  and  the  temperature,  which  had 
been  ioi°,  rose  to  105°,  the  pulse  being  130. 

On  the  third  day  the  convulsions  became  less  frequent, 
and  were  limited  to  the  face  and  right  arm ;  and  on  the 
fourth  day  the  left  arm  became  rigid,  and  the  convulsions 
were  limited  to  the  face  and  left  arm.  The  temperature 
dropped  to  101°,  and  became  normal  two  days  later. 

During  the  next  few^  days  she  opened  her  eyes  occasion- 
ally ;  but  there  was  no  expression  in  them,  the  patient  being 
still  unconscious  of  her  surroundings.  Ten  days  after  the 
beginning  of  her  illness  her  husband  stood  by  the  bed  for 
several  minutes,  trying  to  make  her  recognize  him  ;  but  she 
showed  no  sign  of  intelligence.  An  hour  later,  however, 
she  turned  to  the  nurse  and  told  her  all  about  her  hus- 
band's visit,  apparently  considering  it  a  great  joke  that  he 
had  thought  her  unconscious.  At  this  time  the  knee-jerks 
were  much  exaggerated  and  equal. 

Two  weeks  after  the  beginning  of  her  illness  she  was 
able  to  sit  up  in  bed,  but  refused  to  help  herself,  saying 
that  her  hands  were  powerless.  Food  was  placed  before 
her,  but  she  said  she  could  not  feed  herself.  After  five 
minutes  it  was  taken  away,  and  she  became  very  angry- 
Six  hours  later  she  was  offered  food  again,  and  ate  natu 
rally  without  assistance. 

Although  the  patient  had  apparently  recovered  at  the  end 


i6o 

of  three  weeks,  still  she  behaved  at  times  in  a  peculiar 
manner.  She  would  often  wander  about  the  house  in  an 
aimless  sort  of  a  way,  and  on  one  occasion,  after  a  bath, 
started  out  of  the  bath-room  before  dressing  herself. 

CXXVIII. 

Right  Ophthalmoplegia^  Left  Hemi-ancesthesia   and  Hemi- 

paresis. 

A  minister,  fifty  years  old,  awoke  one  morning  to  find 
that  he  could  not  open  his  right  eye  as  well  as  usual  and  that 
the  whole  left  half  of  the  body  was  *'numb."  He  kept 
about  as  before,  but  began  to  notice,  after  the  lapse  of  a 
few  days,  that  besides  the  drooping  of  the  lid  he  was  get- 
ting double  vision. 

By  the  end  of  the  second  week  it  was  noticed  that  he 
scuffed  his  left  foot  in  walking ;  and  during  the  next  few 
days  his  left  arm  and  leg  grew  progressively  weaker,  so 
that  by  three  weeks  from  the  onset  of  his  trouble  he  was 
unable  to  stand  and  became  confined  to  his  bed. 

There  had  been  no  headache  nor  vomiting,  and  no  dis- 
order of  micturition.  His  friends  had  not  noticed  any  change 
in  his  disposition ;  and  he  declared  that  he  had  felt  perfectly 
well  up  to  the  time  of  the  beginning  of  his  illness,  and 
denied  having  had  any  venereal  disease. 

Physical  examination  shows  a  well-developed  and  well- 
nourished  man.  There  is  complete  ptosis  of  the  right  eye- 
lid and  paralysis  of  all  the  external  muscles  of  the  right  eye, 
while  the  left  eye  moves  fairly  well  in  every  direction.  The 
right  pupil  is  dilated,  and  the  left  pupil  contracted.  Both 
are  regular  in  outline,  but  neither  responds  to  light. 

The  tongue  is  protruded  in  the  median  line.  The  speech 
is  thick  and  at  times  hard  to  understand. 

There  is  complete  left  hemi-anaesthesia  and  also  paresis 
of  the  lower  facial  muscles  on  the  left  side.  Movements  of 
the  left  arm  and  leg  are  very  feeble  and  performed  with 
difficulty. 


i6i 

The  heart  sounds  are  normal,  the  pulse  rate  go,  the  im- 
pulse regular,  and  the  arterial  tension  low.  There  is  no 
evidence  of  thickening  of  the  artery  wall  in  the  radial  and 
temporal  vessels.  The  knee-jerks  are  equal  and  not  exag- 
gerated :  the  Bakinski  phenomenon  is  present  on  the  left 
side.  The  mental  condition  is  dull.  The  patient  multiplies 
the  digits  promptly  and  correctly,  but,  when  asked  to  name 
the  months  of  the  year,  he  begins  with  April,  and  goes  slowly, 
but  correctly,  around  to  July.  On  being  questioned  as  to 
when  he  was  out  of  doors  last,  he  says  he  was  out  walk- 
ing a  few  hours  ago, —  a  thing  he  has  not  done  for  a 
week. 

CXXIX, 

Transitory  Hemiplegia  during  Typhoid ;  followed  by  Attacks 
of  Parcesthesia  in  the  Left  Ha7id  a?id  occasionally  Loss 
of  Conscious7iess. 

Male  patient,  unmarried,  twenty-one  years  of  age,  first 
seen  April  7,  1890. 

The  patient  reports  that  he  was  perfectly  well  up  to  three 
and  a  half  years  ago  (October,  1886).  No  convulsions  in 
infancy ;  family  history  good.  At  the  date  just  mentioned 
he  was  taken  sick  with  a  continued  fever,  believed  to  be 
typhoid,  which  lasted  for  thirteen  weeks.  In  the  very  first 
stage  of  this  illness  his  father  went  into  his  room  and  found 
him  unconscious ;  but  he  soon  regained  his  senses,  and 
seemed  as  well  as  before.  Two  or  three  weeks  later,  while 
in  the  height  of  the  fever,  and  while  suffering  from  severe 
pain  in  the  head,  especially  on  the  right  side,  he  felt  his 
lefc  hand  numb  one  day,  and  almost  immediately  after  this 
became  entirely  paralyzed  on  the  left  side.  The  face,  arm, 
and  leg  were  involved ;  and  at  first  there  was  difficulty  in 
swallowing.  At  this  same  period  he  was  unable  to  open 
the  right  eye,  and  suffered  from  double  vision.  The  pain  in 
the  head  lasted  three  or  four  weeks.  The  paralysis  began 
to  pass  away  after  a  few  weeks,  and  before  long  had  entirely 


l62 

disappeared  except  perhaps  for  slight  traces.  About  two 
years  after  these  circumstances,  his  health  in  the  mean  time 
having  been  good  and  his  mental  power  excellent,  he  began 
to  suffer  from  the  attacks  for  which  he  sought  my  advice. 
These  consisted  in  peculiar  and  indescribable  sensations  in 
the  left  hand,  spreading  thence  up  the  arm  and  sometimes 
attacking  the  left  cheek,  where  the  feeling  was  described 
as  burning  in  character.  Occasionally  there  would  be  a 
strange  sensation  in  the  head,  described  as  "  rush  of  bload," 
before  the  numbness  in  the  hand.  He  thinks  the  leg  was 
not  involved  in  the  slighter  seizures,  but  says  that  during 
convalescence  from  a  severe  attack  it  would  feel  heavy  and 
clumsy.  Most  of  the  attacks  consisted  solely  of  these 
abnormal  sensations,  which  would  increase  for  one  or  two 
minutes,  then  gradually  diminish,  but  without  wholly  disap- 
pearing until  after  perhaps  ten  minutes.  Sometimes  even 
later  than  this,  slightly  unnatural  sensations  remained,  asso- 
ciated with  a  sense  of  weakness  and  helplessness  in  the  hand. 
In  connection  with  this  numbness  the  fingers  would  some- 
times twitch  a  little  ;  and  a  few  times,  perhaps  six  in  all,  he 
had  lost  consciousness,  sometimes  biting  the  tongue  and  hav- 
ing a  full  convulsion.  The  attacks  were  not  accompanied  by 
any  marked  disturbance  of  speech.  On  two  occasions  he 
had  had  a  slight  blurring  of  the  vision,  not  attended  by 
numbness  of  the  hand,  and  lasting  one  or  two  hours. 
The  remainder  of  the  history  will  be  given  during  the 
discussion. 

cxxx. 

Gastric  Symptoms  ;    Vertigo  ;  Morbid  Fear. 

The  patient  is  forty-two  years  old,  unmarried,  a  nurse  by 
profession.  She  was  always  of  nervous  temperament,  but 
had  quite  a  collapse  after  the  grippe,  three  years  ago,  and 
has  never  been  well  since  then.  She  now  complains  of  a 
tight  feeling  round  the  head,  and  at  times  has  severe  ver- 
tigo,   especially   if   there   are  noises  about  her.     With  the 


i63 

vertigo  there  is  apt  to  be  sense  of  confusion  in  the  head. 
After  being  ill  for  a  year,  she  went  to  the  Adams  Nervine 
Hospital,  where  she  remained  for  another  year,  five  months 
of  it  in  bed.  She  improved  somewhat,  but  had  a  great  deal 
of  distress  after  eating,  besides  nausea,  vomiting,  and  a 
continuance  of  the  dizziness.  After  leaving  there,  she 
suffered  violently  from  nausea  and  lost  flesh  and  strength. 
Scarcely  any  food  could  be  retained.  For  the  past  four 
months  she  has  had  no  vomiting,  but  a  great  deal  of  gastric 
distress  whenever  she  is  fatigued.  Besides  these  special 
symptoms  there  are  certain  others  which  seem  to  shade  over 
into  them.  Thus  it  distresses  her  greatly  to  go  over  the 
stairs,  partly  because  it  causes  a  feeling  of  dizziness  and 
partly  on  account  of  a  "  sort  of  fear  "  which  comes  over  her. 
This  sense  of  fear  she  has  been  subject  to  ever  since  she  was 
a  child. 

Thirteen  years  before  the  first  examination  she  had 
been  a  teacher ;  then  she  had  broken  down  entirely,  and 
among  her  symptoms  at  that  time  this  strange  dizziness 
figured  prominently.  Half  a  dozen  years  after  that  she  had 
a  double  ovariotomy  performed,  on  account  of  a  supposed 
closure  of  the  Fallopian  tube,  and  after  this  she  was  so 
much  better  that  she  entered  a  hospital  to  be  trained  as  a 
nurse.  She  has  never  had  any  reason  to  think  the  operation 
led  to  unfavorable  results,  and  a  pain  in  the  abdomen  from 
which  she  had  suffered  severely  before  that,  disappeared 
immediately  afterward.  The  eyes  had  troubled  her,  and 
glasses  had  not  done  her  much  good. 

The  vertigo,  of  which  she  constantly  spoke,  proved,  on 
further  inquiry,  to  be  rather  a  sense  of  up  and  down  motion, 
combined  with  a  feeling  as  if  the  floor  or  sidewalk  was 
rising  in  front  of  her,  and  then  falling  again. 

Physical  examination  showed  a  normal  condition  of  the 
heart,  except  that  the  sounds  were  sharp  and  "valvular." 
The  hands  were  the  seat  of  a  fine  tremor,  the  muscular 
system  was  poorly  developed,  and  the  general   nutrition  not 


164 

very  good.  This  patient  was  most  persistent  and  conscien- 
tious in  following  out  a  good  hygienic  treatment,  and  gained 
somewhat,  but  still  remained  a  prey,  when  fatigued,  to  symp- 
toms of  the  above-mentioned  character. 

CXXXI. 

Occasional  Fainting  Spells. 

A  man  of  forty-five,  of  excellent  habits  and  with  no  his- 
tory of  venereal  exposure,  was  attacked  in  June,  1901, 
with  a  "fainting  spell."  His  occupation  was  that  of  a 
butler;  and  he  was  working  in  the  pantry  at  the  time, 
cleaning  knives.  When  the  attack  came  on,  he  fell  sud- 
denly to  the  ground  unconscious,  without  warning.  He  re- 
mained unconscious  for  twenty  minutes,  it  was  said ;  and, 
after  coming  to  himself,  he  felt  weak  and  had  a  vague 
sense  of  something  having  gone  wrong,  though  he  could 
not  say  what.  An  hour  after  this  he  was  able  to  go  to  work 
again.  After  that  he  was  entirely  well  until  eight  months 
later,  except  for  being  rather  nervous. 

At  the  end  of  that  period,  however,  he  had  another  at- 
tack of  similar  character,  recurring  as  before  at  about 
eleven  o'clock  in  the  forenoon.  He  was  again  unconscious 
for  twenty  minutes,  and  afterwards  had  no  memory  of  the 
occurrences  during  that  period.  He  did  not  bite  his  tongue 
in  either  of  these  attacks,  nor  did  he  become  convulsed. 

In  other  respects  his  health  has  been  excellent,  except 
that  his  eyesight  has  been  failing  somewhat,  he  thinks.  He 
can  read  perfectly  well  without  glasses,  but  a  sort  of  dim- 
ness comes  over  the  field  of  vision  every  now  and  then. 
He  never  had  any  attacks  attended  with  loss  of  conscious- 
ness before,  not  even  in  childhood.  His  sleep  is  good,  his 
digestion  good.  The  pupils  react  normally  to  light.  The 
knee-jerks  are  present  on  both  sides. 

The  heart  beats  with  a  thumping  impulse.  The  pulse  ten- 
sion is  very  high  (700  to  800  grams),  and  the  walls  of  the  radial 


i65 

artery  are  thick  and  the  course  of  the  vessel  is  tortuous. 
The  arteries  of  the  foot  are  normal.  The  retinal  arteries 
vary  in  size  in  different  parts  of  their  course. 

This  patient  was  given  ten  grams  of  iodide  of  potash 
twice  a  day,  and  2^0  g^-  nitroglycerine  four  times  a  day ; 
and  these  he  continued  to  take  for  a  number  of  months. 
A  year  later  he  called  again,  saying  that  he  had  felt  very 
well  indeed  and  had  had  no  attacks,  but  the  pulse  tension 
was  still  very  high  (500  to  600  grams.) 

CXXXII. 

Epileptiform  Seizures ;  Slight  Mental  Defect  (?) 

A  man  of  forty-six,  not  admitting  any  luetic  infection, 
had  an  attack  on  June  14,  1902,  while  riding  in  a  car  in 
the  subway,  in  which  he  had  lost  consciousness.  He  was 
taken  to  the  Emergency  Hospital  at  Haymarket  Square; 
and  when  he  came  to  himself,  an  hour  or  two  later,  he 
could  remember  nothing  of  what  had  happened.  It  was, 
however,  said  by  bystanders  that  he  had  had  a  convulsion. 

On  inquiry  it  was  found  that  about  a  year  previously  he 
had  had  another  attack  of  similar  sort  to  this,  but  even 
worse.  He  was  unconscious  for  a  number  of  hours  in  all, 
and  in  that  time  had  four  or  five  convulsions.  Three  years 
ago  he  was  in  a  very  nervous  state,  but  had  no  convulsion 
or  loss  of  consciousness.  A  year  ago  it  was  found  that  the 
urine  contained  albumen  and  casts  for  a  time ;  but  a  very 
careful  physician  decided,  after  thorough  investigation,  that 
he  had  no  chronic  nephritis,  and,  in  fact,  the  suspicious 
signs  disappeared  before  long.  In  former  years  he  used 
to  have  headaches,  but  during  the  past  three  years  these 
have  been  almost  absent. 

His  wife  reports  that  his  mental  condition  is  not  quite 
what  it  should  be,  that  he  takes  less  interest  in  affairs,  and 
is  more  childish  than  formerly.  He  spends  a  long  time 
over  his  newspaper,  and  is  unwilling  to  go    out   with   his 


i66 

friends  as  usual.  She  says,  also,  that  he  makes  statements 
of  facts  that  are  not  quite  accurate.  Thus  he  announced 
one  day  that  he  had  bought  a  yacht,  and  gave  the  price, 
etc. ;  yet  this  was  by  no  means  true.  It  should  be  said  that 
shortly  after  the  epileptic  attack  first  mentioned  he  was 
put  on  a  bromide  treatment  which  he  has  followed  ever 
since,  though  he  never  took  more  than  60  grs.  a  day,  and 
usually  less  than  this. 

A  careful  examination  of  the  pupils  revealed  nothing 
wrong.  The  knee-jerks  were  normal,  and  the  heart  normal. 
On  the  other  hand,  the  speech  was  a  little  obscure  and 
thick,  and  the  handwriting  was  careless.  When  asked  to 
write  a  short  sentence,  he  misspelled  some  words  with 
which  he  should  have  been  familiar. 

No  disturbance  of  the  gait  could  be  noticed. 

Under  a  change  of  treatment  this  patient  improved  very 
materially,  so  that  by  the  end  of  a  few  weeks  more  his 
friends  considered  his  mental  condition  normal. 

CXXXIII. 

Vertigo  with  Ear  Disease. 

This  patient  was  a  man  of  thirty-nine,  who  consulted  me 
in  April,  1900.  His  previous  health  had  been  good  in  most 
respects  ;  and  he  thinks  that  he  was  not  "  nervous  "  until  his 
present  illness  began,  though  through  the  distressing  influ- 
ence of  his  present  troubles  he  has  become  so  nervous  that 
everything  startles  him.  As  a  child,  he  suffered  from  sick 
headaches  which  used  to  last  a  day.  His  father  also  suffers 
from  sick  headaches,  and  also  two  brothers,  one  of  his  own 
children,  and  his  wife. 

His  principal  symptoms  consist  in  attacks  of  vertigo,  with- 
out loss  of  consciousness  and  coming  on  without  obvious 
cause.  As  these  attacks  approach,  the  objects  which  he 
looks  at  seem  to  move,  giving  him  a  feeling  as  if  he  must 
close  his  eyes.     He  has  had  these  attacks  for  five  years,  and 


i67 

they  may  occur  at  any  hour  of  the  day  and  under  a  variety 
of  circumstances.  At  times  this  apparent  movement  of  ob- 
jects is  followed  by  a  sensation  as  if  some  one  had  struck 
him  on  the  back  of  the  head.  He  does  not  think  that  the 
movement  of  objects  is  always  in  the  same  direction ;  but, 
however  this  may  be,  he  is  no  sooner  attacked  than  he  turns 
as  ''white  as  a  sheet,"  and  then  begins  to  perspire  so  that 
the  sweat  rolls  off  of  him  in  great  quantities,  wetting  his 
clothes  through  and  through.  Then  he  begins  to  vomit,  and 
this  is  repeated  half  a  dozen  times.  He  vomits  not  only 
food,  but  great  quantities  of  mucus  and  fluid.  A  bad  at- 
tack may  last  from  an  hour  to  an  hour  and  a  half,  and  then 
a  day  or  two  may  pass  before  he  gets  over  the*  effects  of  it, 
during  which  time  he  lies  in  a  stupor,  suffering  greatly 
from  pain  in  the  back  of  the  head.  Physical  examination 
reveals   nothing  abnormal. 

CXXXIV. 

"  Dizziness  and  Hemi-parcesthesia,  of  Sudden  Onset. 

A  lady  of  fifty-one,  who  presented  an  appearance  of  ro- 
bust health,  came  for  treatment  on  account  of  dizziness  and 
ringing  in  the  left  ear.  She  said  that  she  had  always  had 
perfect  health  until  about  two  months  before  her  visit.  At 
that  time  she  woke  up  one  morning  feeling  as  if  she  could 
not  breathe,  and  springing  out  of  bed  came  into  her  hus- 
band's room.  He  could  see  nothing  wrong  with  her,  but 
almost  immediately  she  began  to  feel  as  if  a  battery  was 
being  applied  to  the  left  side  of  her  head  and  face  and  left 
arm  and  leg.  For  a  time  she  was  confused,  and  her  left 
arm  and  leg  were  weak  and  awkward.  Possibly  there  was 
a  momentary  loss  of  consciousness.  The  speech  was  not 
affected,  except  to  the  extent  of  being  slightly  thick  for  a 
brief  period.  Ever  since  that  attack  the  parsesthesia  of  the 
left  limbs  and  left  side  of  the  face  has  been  constantly  with 
her.     There  has   also  been  a  continual  ringing  in  the  left 


i68 

ear ;  and  the  skin  of  the  face  in  the  neighborhood  of  the  ear 
has  had  a  numb,  unnatural  feeling.  There  has  also  been  a 
sensation  as  if  there  was  a  ball  in  the  ear ;  and  yet  there  has 
been  no  loss  of  hearing,  but  rather  a  hyper-acusis.  She  has 
also  been  constantly  dizzy  in  some  measure. 

She  seemed,  at  first,  in  a  perfectly  normal  condition ;  but 
on  very  close  inspection  it  was  noticeable  that,  when  she 
put  her  tongue  out,  there  was  the  slightest  bit  of  drawing 
of  the  face  toward  the  right  side,  and  that  the  right  naso- 
labial fold  was  slightly  more  pronounced  than  the  left.  The 
motions  of  the  left  arm  and  leg  were  good ;  but  the  sense 
of  position  was  not  quite  perfect,  nor  the  power  of  recog- 
nizing small  objects.  Still,  she  said  she  could  use  that  hand 
just  as  well  as  the  other.  The  examination  of  the  heart 
showed  nothing  abnormal  except  a  sharp  accentuation  of 
the  second  aortic  sound ;  but  the  pulse  tension  was  very 
high,  600  to  700  grams,  the  usual  pressure  being  about  300. 

The  urine  contained  the  slightest  possible  trace  of  albumen 
and  occasional  hyaline  casts,  but  no  sugar. 

Under  iodide  of  potassium  and  nitro-glycerine  the  symp- 
toms became  less  marked,  but  still  showed  a  strong  tendency 
to  persist. 

cxxxv. 

Vertigo. 

This  patient  was  a  young  man  of  nineteen,  of  good  per- 
sonal and  family  history,  with  the  exception  that  his  mother 
was  of  nervous  temperament  and  that  he  himself  had  had 
some  catarrhal  trouble  of  the  left  ear  for  the  past  two  years, 
with  marked  impairment  of  hearing  and  constant  tinnitus. 

Two  years  ago  he  suffered  greatly,  for  three  or  four 
months,  from  dizziness  on  walking.  Next  he  had  an  at- 
tack of  severe  dizziness  with  vomiting  in  the  night,  so  that 
for  a  couple  of  hours  he  could  not  raise  his  head  without 
vomiting  and  a  feeling  as  if  objects  were  whirling  about. 
From  time  to  time  these  attacks  have  recurred.     One  day, 


169 

when  he  was  sitting  at  table,  he  fell  from  his  chair  to  the 
floor,  and,  as  he  thinks,  lost  consciousness,  for  which  reason 
he  cannot  give  an  exact  statement  as  to  whether  dizziness 
was  present  or  not.  At  this  time  he  had  been  several 
months  without  attacks,  but  they  then  returned. 

About  a  month  ago  he  had  a  severe  attack,  associated 
with  a  sort  of  noise  as  if  some  one  was  giving  him  a  clap 
on  the  ear.  Sometimes  sitting  in  a  rocking-chair  and  look- 
ing out  of  the  window,  or  gazing  out  of  the  train  at  passing 
objects,  or  even  watching  another  person  who  is  rocking, 
will  bring  on  an  attack. 

The  first  sign  of  an  attack  is  usually  a  feeling  as  if  the 
objects  at  which  he  is  looking  were  beginning  to  move. 
Then  the  dizziness  comes  on ;  and,  after  this,  if  the  attack  is 
severe,  he  begins  to  vomit.  Even  when  the  attack  has 
passed  away,  his  head  feels  heavy  all  day  long,  and  he  is 
greatly  prostrated. 

Careful  treatment  by  large  doses  of  quinine  and  other 
remedies  brought  some  relief,  but  did  not  induce  a  com- 
plete cure. 

CXXXVI. 

Vertiginoid  Attacks. 

This  patient  is  an  unmarried  lady  of  thirty-two,  a  teacher 
by  occupation.  At  intervals  from  one  to  five  weeks  she 
suffers  from  a  queer  feeling  in  the  head,  suggesting  dizzi- 
ness yet  not  associated  with  an  actual  ''  swimming  "  sensa- 
tion. Sometimes,  unless  she  lies  down  at  once,  she  has  as 
much  as  she  can  do  to  keep  her  feet.  If  attacked  while  in 
school,  she  can  hardly  get  out  of  the  room.  Occasionally 
she  gets  deathly  sick  at  the  stomach,  and  sometimes  feels  as 
if  choking  for  breath.  Usually  she  gets  pale  with  the  at- 
tacks, and  still  more  after  them.  They  last  for  five  minutes, 
and  leave  her  feeling  much  done  up.  There  is  loss  of  con- 
sciousness. At  the  time  of  the  attacks  there  is  often  a 
sound  of  escaping  steam  in  the  ears,  and  a  sense   of  rum- 


I/O 

bling  in  the  head.  At  such  times  she  cannot  hear  quite 
well,  but  there  is  no  permanent  defect,  and  at  a  careful  ex- 
amination of  the  ears  at  the  Eye  and  Ear  Infirmary  no  local 
disease  was  found.  Neither  could  any  trouble  be  detected  in 
the  eyes.  When  she  staggers,  the  tendency  is  quite  definite 
to  go  toward  the  right.  Her  general  health  is  not  good  ;  but 
a  thorough  tonic  treatment,  such  as  she  was  able  to  secure, 
did  not  bring  about  relief. 

CXXXVII. 

Sudde7i  Attack  of  Convulsion  of  the  Right  Arm  mid  Leg,  last- 
ing Half  an  Hour  or  More,  afid  terminating  in  Partial 
Hemiplegia. 

A  somewhat  elderly  man,  unmarried,  and  in  his  youth 
troubled  with  syphilis,  had  suffered  for  many  years  from 
tabes.  He  bore  his  sufferings  with  great  courage,  but 
became  finally  odd  and  irritable  in  disposition.  One 
morning  his  physician  was  called  to  him  in  great  haste,  and 
on  arriving  found  him  in  bed,  with  the  right  leg,  and  to  a 
less  degree  the  right  arm,  in  a  clonic  convulsion.  The 
whole  leg  was  aft'ected ;  and  the  movements,  though  not  very 
extensive,  were  sufiicient  to  shake  the  bed.  The  arm  was 
much  less  severely  involved,  and  the  face  not  at  all.  The 
patient  was  flushed,  but  conscious  and  able  to  discuss  his 
condition.  After  half  an  hour  or  so  the  convulsion  gradually 
subsided ;  but  the  leg  was  left  in  a  helpless  condition  from 
which  it  never  wholly  recovered,  though  he  was  quite  soon 
able  to  go  about  with  some  aid.  His  spinal  symptoms  were 
not  very  much  modified  by  this  attack ;  but  he  grew  gradu- 
ally worse,  and  died  by  the  end  of  another  year.  Before  the 
end  of  this  time  the  arm  had  substantially  recovered,  though 
the  leg  still  remained  with  its  movements  impaired. 

At  tht  post-mortem  examination  a  linear  scar,  of  reddish- 
brown  color  and  about  three  quarters  of  an  inch  in  length, 
was  found  a  short  distance  beneath  the  cortex  of  the  para- 


171 

central  lobule,  running   parallel  with  the  surface.     There 
was  no  other  cerebral  lesion  of  a  macroscopic  character. 

CXXXVIII. 

Paroxysmal    Vertigo    and  Attacks   of    Unusual  Form,    with 
Loss  of  Coiiscious7iess, 

This  patient  was  a  man  of  thirty-two,  a  letter-carrier  by 
occupation,  of  good  habits  as  regards  stimulants,  and  free 
from  specific  diseases.  For  several  months  he  had  suffered 
from  severe  attacks  of  vertigo,  and  for  more  than  a  year 
before  that  there  had  been  a  slight  "  lightness  "  in  the  head 
on  rising  in  the  morning.  The  attacks  of  vertigo  also  gen- 
erally came  in  the  morning,  sometimes  before  he  got  up, 
and  sometimes  not  until  breakfast  time.  The  feeHng  was 
like  that  of  a  person  who  has  been  whirling  round  and 
round.  Occasionally  he  has  had  nausea  and  vomiting  as 
well  as  dizziness.  He  has  never  actually  fallen,  but  stag- 
gers about  like  a  drunken  man.  One  would  naturally  wish 
to  know  the  condition  of  his  auricular  apparatus ;  and,  in 
fact,  there  had  been  catarrh  of  one  ear,  with  slight  defect 
of  hearing,  for  a  long  time  past,  and  a  later  examination 
by  Dr.  J.  Ome  Green  showed  that  there  was  fixation  of  the 
stapes,  by  which  the  labyrinthian  pressure  was  increased. 
There  was  also  some  error  of  refraction,  but  the  correction 
of  this  by  glasses  brought  him  no  relief.  . 

As  regards  his  general  health,  he  had  always  been  a  man 
of  nervous  temperament ;  readily  tired  and  not  a  first-rate 
sleeper.  Furthermore,  even  when  a  child,  he  used  to  have 
attacks,  in  which  he  would  run  to  his  mother,  calling  out 
that  he  was  "thinking  of  something  which  frightened  him," 
but  he  could  not  tell  what  it  was.  He  says  now  that  it  is 
more  as  if  he  stopped  thinking  for  a  moment.  He  also  had 
"spasms"  as  a  child.  Attacks  similar  to  these  just 
mentioned  still  occur  about  once  a  month,  lasting  for  half 
a  minute.     They  are  so  slight  that  no   one    would   notice 


1/2 

anything  wrong  except  perhaps  a  sudden  paleness,  but  this 
is  so  marked  that  people  occasionally  ask  him  if  he  feels 
sick.  He  does  not  lose  consciousness,  and  can  go  on 
with  what  he  is  doing.  Formerly  these  attacks  used  to  be 
followed  by  violent  headache,  lasting  for  many  hours  or  a 
day ;  but  now  this  tendency  is  not  marked.  These  seizures 
are  not  followed  by  dizziness. 

His  father  is  a  man  of  nervous  temperament  and  alcoholic 
in  his  habits,  though  otherwise  well.  His  mother  was  not 
a  strong  woman,  and  several  of  her  family  had  died  with 
tuberculosis. 

The  attacks  of  dizziness  were  so  bad  and  so  little  con- 
trolled by  any  treatment  that  Dr.  Green  decided  to  operate 
on  the  ear,  for  the  purpose  of  loosening  the  stapes.  For  a 
time  there  was  great  improvement,  so  that  he  had  no  attack 
for  ten  weeks,  though  the  hearing  in  the  affected  ear  was 
lost.  Then  the  attacks  began  to  return ;  and  occasionally 
he  would  fall  over  in  them,  either  to  his  knees  or  com- 
pletely to  the  ground.  In  one  such  attack  he  thinks  he  lost 
consciousness  for  a  moment  before  falling,  and  that  the  fall 
occurred  on  that  account.  He  came  to  himself,  however, 
instantly,  though  he  could  not  get  up  until  the  dizziness  had 
passed  away,  which  was  not  for  fifteen  or  twenty  minutes. 
Even  after  that  he  staggered  about  for  half  an  hour  or  more. 
The  other  seizures  also  continued,  though  they  were  some- 
what susceptible  to  treatment. 

CXXXIX. 

Headache. 

This  patient  was  a  boy  of  eleven,  who  had  been  the 
rounds  of  the  doctors  on  account  of  harassing  headaches, 
which  had  broken  into  his  usual  habits  of  life  and  had  kept 
him  from  school  most  of  the  time  for  more  than  a  year. 
At  first  they  used  to  come  at  intervals  of  one  or  two  weeks, 
and  last  only  for  a  part  of  the  day.     Then  they  became 


^73 

more  frequent,  until  finally  they  occurred  daily.  The  seat 
of  the  pain  was  just  above  the  root  of  the  nose,  and  it 
never  extended  much  beyond  that  area.  At  one  time  the 
nose  was  thoroughly  cauterized,  under  the  impression  that  a 
thickening  of  the  mucous  membrane  might  account  for  the 
trouble ;  and,  indeed,  this  was  followed  by  an  interval  of 
freedom  from  headache  of  three  months'  duration.  Encour- 
aged by  this  success,  the  parents  urged  a  repetition  of  the 
treatment ;  but  this  time  it  gave  no  relief. 

The  eyes  were  examined  over  and  over  again  by  different 
oculists  and  a  diffuse  choroiditis  was  found,  considered  as 
probably  congenital.  [Conditions  of  this  sort  do  not,  in- 
deed, usually  cause  headaches  ;  but  there  are  conditions 
under  which  any  strain  may  contribute  to  such  a  result.] 
Use  of  the  eyes  did  not,  however,  increase  the  pain.  The 
eye  muscles  were  then  found  to  be  a  little  at  fault;  and 
prisms  were  advised,  but  gave  no  relief.  Instillations  of 
atropine  were  used  daily,  to  secure  relaxation  of  the  ac- 
commodation ;  but  this,  too,  did  no  good.  He  had  no 
coryza,  and  was  generally  free  from  colds.  He  was  fre- 
quently dizzy,  and  the  objects  he  looked  at  seemed  to  move. 
Neither  going  to  school  nor  studying  made  the  pain  worse ; 
but  he  got  up,  as  a  rule,  feeling  so  wretchedly  on  account  of 
the  pain  that  he  preferred  to  lie  in  bed,  and,  in  fact,  he  had 
not  been  to  school  for  six  weeks. 

Examination  of  the  blood  and  urine  showed  normal  con- 
ditions. He  was  a  bright  boy,  but  excitable  and  restless 
and  curious  about  everything,  and  intense  in  his  play.  He 
slept  fairly  well,  but  would  wake  early,  and  when  asleep 
would  grind  his  teeth.  Through  the  greater  part  of  his 
childhood  he  seems  to  have  been  well  enough;  but  he  had 
been  born  at  eight  months,  and  weighed  then  only  four 
pounds,  and  was  kept  alive  with  difficulty  in  an  incubator. 
He  is  an  only  child  ;  and  the  mother  and  father  are  both  of 
nervous  temperament,  though  otherwise  well.  One  brother 
died  of  tuberculosis  in  infancy. 


174 

Besides  these  headaches,  this  boy  has  been  greatly 
troubled  by  occasional  attacks  of  two  other  sorts.  One  of 
these  is  dizziness,  coming  on  in  sudden  "  spells"  without  ap- 
parent cause.  While  these  spells  last,  which  is  from  a  few 
minutes  to  half  an  hour,  he  is  not  able  to  walk  without  stag- 
gering ;  and  the  fear  of  them  makes  him  anxious  and  distrust- 
ful of  himself.  Consciousness  is  nol  disturbed  during  these 
attacks  of  dizziness,  but  he  feels  sick  and  looks  pale.  The 
other  attacks  occur  at  much  longer  intervals,  perhaps  four 
or  five  times  a  year ;  but  he  has  had  them  ever  since  he  was 
three  years  old.  In  these  attacks  consciousness  is  lost  for 
a  moment,  and  its  recovery  is  rather  sudden.  They  gen- 
erally occur  in  connection  with  some  exciting  cause.  Thus 
he  had  one  after  cutting  his  finger ;  and,  after  being  vacci- 
nated, he  had  a  long  series  of  them,  covering  in  all  about  an 
hour  or  more.  In  these  attacks  the  muscles  are  contracted 
all  over  the  body,  the  arms  are  slowly  flexed,  and  the  eyes 
are  "  set."  The  tongue  is  not  bitten ;  but,  as  the  attack 
comes  on,  there  is  often  a  spasmodic  cry. 

The  treatment  which  was  eventually  followed  proved  very 
successful  as  regards  the  headaches,  which  were  his  sole 
cause  of  complaint  at  first ;  and  from  the  time  it  was  insti- 
tuted he  remained  nearly  free  from  pain  for  a  year,  though 
occasionally  suffering  slight  relapses.  Part  of  this  treatment 
consisted  of  the  use  of  static  electricity,  and  it  was  found 
that  he  could  be  easily  thrown  into  first  degree  of  hypnotic 
sleep  during  this  procedure. 

CXL. 

Recurrent  Attacks  of  Numbness  of  the  Right  Hand,  and  Con- 
vulsions of  the  I£a?id,  Arm,  and  Face.      Operation, 

This  patient  was  a  man  of  thirty-two,  of  good  previous 
health,  except  that  he  had  shown  and  still  showed  slight 
signs  of  pulmonary  tuberculosis,  no  longer  in  an  active 
state.     For   nearly   twenty   years  he  had  been   subject   to 


175 

sudden  attacks,  characterized  by  prickly  sensations  in  the 
right  hand,  usually  confined  to  the  first  two  fingers  and 
thumb  and  the  adjoining  surface  of  the  palm.  Occasionally 
these  sensations  would  extend  up  the  arm,  and  would  involve 
the  right  side  of  the  face  and  tongue.  Occasionally,  also,  the 
fingers  and  arm  would  be  the  seat  of  clonic  convulsions. 
These  attacks  have  usually  been  unattended  by  loss  or 
impairment  of  consciousness  ;  but  on  a  few  occasions,  in 
severe  attacks,  consciousness  has  been  lost.  On  such 
occasions  this  loss  has  been  preceded  by  painful  sensa- 
tions, gradually  mounting  up  the  arm  from  the  hand,  as  if 
the  arm  were  being  chopped  off  shorter  and  shorter  by  suc- 
cessive blows  of  an  axe. 

On  careful  examination  the  sensibility  was  found  slightly 
impaired,  both  to  touch  and  pricking  and  to  heat,  over  the 
palmar  surfaces  of  the  last  phalanges  of  the  fore-finger  and 
thumb,  and  perhaps  in  less  degree  over  the  whole  area 
designated  above.  On  Dec.  15,  1899,  this  patient  was 
trephined  over  the  hand-area  of  the  cortex  by  Dr.  J.  C. 
Warren  ;  and  a  small  tough  adhesion  was  found  between 
the  pia  and  dura  mater,  associated  with  opacity  of  the  pia 
over  a  larger  area.  The  pia  and  adjoining  portion  of  the 
cortex  were  removed.  This  was  followed  by  an  extension 
of  the  tactile  anaesthesia  and  parassthesia  to  the  rest  of  the 
hand,  and  by  a  slight  facial  paralysis  and  motor  aphasia. 
The  hand  was  also  quite  weak  for  a  time,  especially  as  re- 
gards movements  requiring  fine  co-ordination,  such  as  but- 
toning. On  the  second  day  after  the  operation  he  had  an- 
other of  the  severer  attacks  with  loss  of  consciousness. 
From  then  up  to  the  present  time  there  has  been  no  re- 
turn of  the  severe  attacks ;  but  the  "numb  spells"  in  the 
hand  have  been  rather  more  frequent  than  before  the  opera- 
tion, and  have  involved  a  somewhat  larger  area.  I  would 
refer  in  this  connection  to  two  other  cases,  the  patients  in 
both  being  young  men,  in  which  a  closely  similar  condition 
was  present.     In  one  of  these  the  attacks  of  paraesthesia 


176 

involved  all  the  fingers  :  in  the  other  they  were  usually  or 
often  confined  to  the  last  two  joints  of  the  index  and  mid- 
dle finger  and  the  last  joint  of  the  thumb,  and  were  quite 
painful  in  character.  In  the  first  case  an  operation  showed 
a  somewhat  extensive  velvety  condition  of  the  pia,  which, 
as  the  history  showed,  had  evidently  resulted  from  a  menin- 
geal inflammation  or  hemorrhage  attending  an  attack  of 
typhoid.  The  other  patient  was  operated  on  by  Dr.  War- 
ren. The  surface  of  the  brain  and  the  membranes  looked 
perfectly  healthy,  and  no  incision  was  made  into  the  cortex. 
The  hand  was  numb  and  weak  for  a  time,  but  soon  recov- 
ered. There  were  no  attacks  for  five  months  ;  but  they  then 
returned,  though  in  a  less  severe  form  than  at  first. 

CXLI. 

Recurrent  Attacks  of  Disturbance   of  Speech,  associated  with 
Numbness  of  the  Right  Arm,  and  Headache. 

A  woman  of  fifty-three,  of  nervous  temperament  and 
neurotic  antecedents  and  subject  to  occasional  sick  head- 
aches, woke  one  morning  feeling  her  right  hand  weak  and 
numb,  and  with  slight  confusion  of  speech,  both  of  which 
symptoms  passed  away  in  the  course  of  half  an  hour.  Two 
days  later  she  had  another,  similar  attack  ;  and  subsequently 
they  recurred  a  good  many  times,  at  intervals  of  a  month  or 
two.  Sometimes  the  difficulty  of  speech  showed  itself  with- 
out any  affection  of  the  hand.  The  attacks  were  usually 
followed  by  slight  headache.  The  urine  was  normal  in  all 
respects,  the  heart  and  arteries  were  normal,  and  nothing 
unusual  was  found  on  ophthalmoscopic  examination.  There 
had  been  no  loss  of  consciousness  with  any  of  the  attacks. 


177 

CXLII. 

Temporary  Attacks  of  Hemi-ancesthesia. 

A  business  man,  fifty-one  years  old,  had  been  troubled 
during  the  past  year  and  a  half  with  a  tingling  and  numbness 
and  an  actual  los§  of  sensibility,  of  both  feet  and  over  the 
area  of  distribution  of  the  lower  sacral  nerves,  so  that  the 
acLnfjuictxirition  did  not  give  rise  to  the  u^al_sensation. 
He  had  had  no  serious  disease  previously  to  this,  so  far  as 
he  can  remember,  except  that  he  contracted  syphilis  ten 
years  ago.  He  uses  alcohol  and  tobacco  moderately,  and 
lives  a  well-regulated  life.'^ 

One  day,  after  he  had  been  under  more  or  less  irregular 
treatment  for  some  time,  he  suddenly  had  a  feeling  as  if  the 
sjtin  over  the  left^side  of  his  chest  was  being  puckered  up, 
and  this  was  followed  immediately  by  a  sense  of  numbness  in 
the  left  arm  and  leg.  He  was  standing  talking  with  a 
friend  as  this  attack  came  on ;  but  all  at  once  the  left_i£g-. 
b^  its  strength,  so  that  he  almost  fell,  and,  on  trying  to  reach 
out  for  support,  he  found  he  could  not  radge  his  left  arm. 
He  then  tried  to  ask  his  friend  for  help,  but  his  speech  was 
thick  and  unintelligible.  He  was  assisted  to  a  couch  ;  and, 
when  seen  an  hour  and  a  half  later,  he  had  apparently 
recovered. 

Examination  showed  the  pupils  to  be  small  and  slightly 
irregular,  with  almost  no  reaction  to  light.  The  fundus  was 
normal,  except  for  a  small  area  of  old  choroiditis.  Sensa- 
tion and  motion  seemed  unimpaired  over  all  parts  of  the 
body.  The  heart  was  not  enlarged,  but  there  was  a  faint 
diastolic_murmur__in  the  aortic  area,  transmitted  downward 
along  the  left  border  of  the  sternum.  The  pulse  was  regu- 
lar, and  of  fair  volume  and  tension.  There  was  no  apparent 
arterio-sclerosis.  The  knee  jerks  were  present,  but  the 
right  was  a  little  livelier  than  the  left.  The  urine  was 
normal. 

During  the  night  following  the  above-described  attack  the 


178 

patient  had  a  sense  of  heaviness  and  numbness  in  the  left 
arm  and  leg  on  two  occasions.  This  lasted  an  hour  the  first 
time  and  ten  minutes  the  next,  but  neither  time  was  there 
any  loss  of  power. 

Vigorous  treatment  was  begun  at  once  ;  and  there  has 
been  no  return  of  the  trouble  since  then,  a  period  of  two 
years. 

CXLIII. 

Pain  in  the  Head,  Dizziness,  JVatisea,  and  Vomiting ; 
Unsteady  Gait. 

A  man  forty-eight  years  old  had  been  d^ii  on  the  right 
side  since  the  removal  of  a  £ol3^p  from  that  e^ar,  sixteen  years 
previously.  \  Three  months  ago  he  had  pleujisy,  with  exu- 
dation; and  the  convalescence  from  this  was  complicated 
by  left  otitis  media,  resulting  in  rupture  of  the  tympanic 
membrane.  The  ear  discharged  for  three,we.^ljs  ;  and  then 
inflammation  of  the  mastoid  developed,  which  was  operated 
on  two  weeks  ago.  This  left  him  free  from  pain  for  a 
week,  and  then  he  began  to  suffer  from  a  left  supra-orbJtaJ 
and  occipital  headache.  Now,  for  five  days,  he  has  had  diz- 
ziness  and  nausea^  with  continual  vomiting^  and  his  gaij 
has  been  unsteady.  The  temperature  has  been  somewhat 
elevated  (99°-ioi°),  and  the  the  pulse  rate  is  60  to  the 
minute. 

Examination  shows  the  mental  condition  of  the  patient  to 
be  normal.  There  is  considerable  photophobia ;  but  the 
pupils  are  equal  and  react  normally,  and  the  fundus  is 
normal.  There  are  no  signs  of  any  disturbance  of  sensa- 
tion or  motion  of  the  extremities,  except  in  the  left  arm, 
which  shows  marked  inco-ordination.  The  stomach  exam- 
ination shows  no  abnormal  local  condition.  The  knee- 
jerks  are  normal. 

The  urine  is  normal,  and  the  blood  count  shows  11. joqq^ 
whites  per  c.m.m.     Operation  on  the  left  mastoid  showed 
clean  granulation  tissue  and  no  pus.     The  adjoining  dura 
showed  no  evidence  of  any  pathological  condition. 


^J.<uMi^  f  h^uM    ^M.  ^  (M^^'tZti^     /UiU^  • 


179 

The  same  symptoms  persisted  after  the  operation.  Sur- 
gical aid  was  resorted  to  a  second  time,  and  resulted  in  a 
cure. 

CXLIV. 

Headache,   Vomiting,  Optic  Neuritis. 

A  lady  of  thirty-eight,  with  a  good  personal  history  and 
free  from  all  suspicion  of  venereal  disease,  began  to  suffer 
from  rather  severe  headaches  in  the  summer  of  1884.  These 
headaches  were  not  constant,  but  intermittent ;  and  the  pain 
generally  passed  away  at  nightfall  after  having  lasted 
through  the  day.  Her  father,  she  said,  had  suffered  from 
attacks  of  more  or  less  similar  character.  These  headaches 
gradually  increased  in  intensity  and  frequency,  until  of  late 
she  has  had  one  or  two  a  week,  although  they  have  not 
been  so  severe  as  to  send  her  to  bed. 

Three  months  before  her  visit  she  had  a  terrific  pain 
which  lasted  for  two  days.  This  occurred  just  before  the 
menstrual  period,  but  ever  since  then  all  the  attacks 
have  been  more  frequent  and  severe.  When  she  wakes  in 
the  morning,  she  feels  "  as  if  she  should  die  "  with  distres- 
sing pain  in  the  forehead  and  sometimes  all  over  the  head 
and  the  back  of  neck.  Sometimes  this  pain  passes  off  in 
an  hour  or  two,  but  it  may  last  a  day.  Twice  within  the 
last  three  weeks  she  has  had  severe  vomiting,  coming  on 
the  first  thing  in  the  morning.  She  has  also  had  a  great 
deal  of  vague  dizziness,  attended  with  an  indistinctness  of 
vision ;  and  her  gait  has  become  a  little  uncertain. 

On  physical  examination  the  patient  was  seen  to  be  a 
healthy-looking  person,  with  a  pleasant  but  somewhat  un- 
natural manner.  She  was  rather  talkative,  yet  at  the  same 
time  apparently  a  little  indifferent  as  regards  her  illness. 
She  could  stand  on  either  foot  alone  even  with  the  eyes  shut ; 
and  yet,  as  she  walked,  it  was  obvious  that  her  sense  of 
balance  was  not  good.  Closure  of  the  eyes  made  no  differ- 
ence.    The  pupils  were  rather  large  in  moderate  light ;  and, 


i8o 

while  the  left  pupil  was  found  to  respond  readily  to  changes 
in  light  intensity,  the  response  of  the  right  pupil  was  much 
less  prompt.  The  right  pupil,  too,  was  much  larger  than 
the  left  pupil.  The  vision  was  considerably  reduced  for 
either  eye,  and  double  optic-neuritis  was  present.  The 
knee-jerks  were  exaggerated.  The  heart  was  in  a  normal 
state,  and  the  pulse  was  normal.  Examination  of  the  urine 
showed  nothing  of  importance. 

As  time  went  on,  this  patient  grew  very  gradually  worse, 
and  finally  lay  for  a  long  time  in  bed,  almost  unconscious, 
yet  never  paralyzed  in  any  of  her  limbs.  The  only  localiz- 
ing sign  was  that  the  right  side  of  the  face  was  slightly  pare- 
tic, while  the  tongue  deviated  slightly  toward  the  right.  The 
optic-neuritis  was  greater  on  the  right  side,  and  more  pain 
was  felt  on  that  side  of  the  head  than  on  the  other  side.  At 
times  the  pain  in  the  back  of  the  neck  was  complained  of 
even  more  than  the  pain  in  the  head.  Speech  grew  gradu- 
ally less  and  less,  until  finally  she  could  answer  questions 
only  by  monosyllables,  and  finally  not  at  all.  Death  seemed 
to  be  due  mainly  to  exhaustion.  The  account  of  the  post- 
mortem examination  will  be  given  with  the  discussion  of  the 
case. 

CXLV. 

Neurasthenia  with  Vaso-motor  Symptoms. 

This  patient  was  a  young  business  man  with  two  healthy 
children.  His  habits  were  good ;  and  his  personal  history 
contained  nothing  of  importance,  except  that  when  a  child  of 
seven  months  he  was  very  ill  and  was  with  difficulty  kept  alive. 

His  principal  symptoms  at  the  time  of  the  first  examina- 
tion were  great  exhausiibility,  palpitation,  and  pains  in  the 
back  and  chest.  Every  effort  was  so  distressing  to  him  that 
he  avoided  his  acquaintances  on  the  train  as  he  came  into 
town  in  the  morning  from  his  home  in  the  suburbs,  and  that 
he  hardly  allowed  himself  to  read.  He  said  that,  one  year 
previously,  he  had  had  a  sort  of  collapse  while  riding  in  the 


train,  for  no  obvious  cause  except  an  absorbing  conversa- 
tion;  but  even  before  that  his  nerve-strength  iiad  been  fail- 
ing in  various  ways.  He  has  not  been  to  church  or  the 
theatre  for  a  long  time,  because  when  in  such  places  he 
finds  himself  with  an  overwhelming  desire  to  get  out.  Even 
riding  in  the  train  is  distressing  to  him  for  the  same  reason. 
He  is  very  sensitive  to  storms.  On  the  slightest  excitement 
he  flushes  very  easily,  and  also  gets  short  of  breath  and  has 
a  sense  of  palpitation  all  over.  Nevertheless,  under  favor- 
able conditions  he  can  do  a  considerable  amount  of  purely 
physical  work,  and  thrives  best  under  an  out-of-door  life. 

Physical    examination    reveals    nothing   of    importance, 
except  the  fact  that  the  patient  looks  in  florid  health. 


CXLVI. 

General  Neurasthenic  Symptoms^  associated  with  Convulsive 
Attacks  endifig  fatally. 

[Case  reported  by  Dr.  E.  W.  Taylor.] 

A  single  man,  thirty-six  years  of  age,  of  good  family  and 
previous  history,  visited  the  World's  Fair  in  1893,  and  while 
there  had  an  attack  of  mental  confusion  and  vertigo  as  he 
was  walking  about  the  grounds.  This  spell  was  not^of  Imig 
diicatian,  and  he  had  no  more  trouble  for  a  year  and  a  half. 
Then  he  had  a  return  of  the  s^ame  symptoms  on  several 
occasions ;  but  they  improved  somewhat  under  treatment, 
though  some  confusion  still  persisted,  especiall^^^hsjj.^Jli£ 
was  in  a  crowd.  He  was  also  troubled  with  a  sense  of 
weakness  in  the  legs,  and  his  head  felt  as  if  it  were  "iSoat- 
ing  in  the  air." 

In  December,  1894,  he  had  two  attacks  of  unconscious- 
ness, associated  with  convulsions.  At  this  time  his  hearing 
became  affected,  so  that  sounds  near  to  him  appeared  to 
come  from  a  distance  ;  and  this  annoyed  him  so  much  that 
he  consulted  an  aurist,  who  removed  some  cerumen  from 
one  ear. 


l82 

During  the  following  eighteen  months  he  was  constantly 
subject  to  morbid  fears,  so  that  he  was  unable  to  walk  in 
crowded  streets  or  to  enter  a  large  building  without  a  vague 
sense  of  apprehension.  In  1896  and  1897  he  had  several 
more  convulsive  attacks,  and  the  symptoms  above  cited 
were  still  a  source  of  much  trouble.  He  had  read  a  good 
deal  in  medical  books,  and  was  greatly  alarmed  over  many 
of  his  symptoms,  to  which  he  attached  undue  importance. 
He  had  no  real  headache,  but  complained  much  of  a  feeling! 
of  fulness  in  the  head  and  of  throbbing,  neuralgiform  pains 
over  the  eyes  and  on  both  sides  of  the  head.  He  grew  very 
timid  about  riding  a  bicycle,  although  he  had  always  been 
accustomed  to  many  forms  of  athletic  sports. 

Whenever  he  visited   his    physician   he   was   always   re- 
assured, andJelt^heitei-iQLJLJdiile.    In  fact,  after  one  visit, 
he  was  able  to  walk  down  Boylston  Street  and  enter  thel 
I  Public  Library,  which  was  more  than  he  had  been  able  to  j 
:  do  for  two  or  three  years. 

A  careful  physical  examination  in  1897  showed  no  evi- 
dence of  organic  disease  of  the  nervous  system,  and  no 
stigmata  of  hysteria.  The  eyes,  however,  showed  a  moder- 
ate~Begfee  of  astigmatism  and  hypermetropia.  The  fundus 
was  normal.  Examination  of  the  urine  was  negative. 
Glasses  were  prescribed,  and  the  use  of  these  gave  completel 
relief  from  the  headaches. 

The  following  letter,  written  by  the  patient  at  this  time,  is 
of  interest :  — 

I  have  postponed  replying  to  your  very  kind  letter  until 
a  sufficient  length  of  time  should  have  elapsed  in  which  to 
determine  definitely  what,  if  any,  change  had  taken  place 
in  my  condition.  My  brother  informs  me  that  he  has  ad- 
vised you  fully  as  to  the  features  of  the  attack  which  I  had 
the  day  I  left  Boston ;  and,  except  to  say  that  it  was  the 
mildest  spell  of  the  kind  which  I  have  ever  had,  and  that 
I  nearly  succeeded  in  controlling  it,  I  think  it  unneces- 
sary to  further  allude  to  it.  Since  my  return  to  Louisville, 
I  feel  that  I  have  slowly  but  surely  gained  ground.     I  have 


Ui/^^^'yf 


i83 

had  no  return  of  the  attacks,  though  on  two  occasions  I  feel 
sure  that,  had  I  yielded,  1  should  have  succumbed  to  these 
spells.  Protracted  conversation,  in  which  1  am  subjected 
to  considerable  mental  strain,  appears  to  be  a  prime  factor 
in  precipitating  them ;  and  on  the  two  occasions  referred 
to  I  was  obliged  to  cease  talking,  not  daring  to  attempt 
a  renewal  for  at  least  five  minutes.  Another  feature  of 
my  case  which  may  or  may  not  be  of  importance  is  the 
fact  that  I  almost  invariably  feel  worse  immediately  after 
meals  than  at  other  times,  though  the  symptom  is  not 
nearly  so  marked  as  before  I  went  to  Boston.  The  glasses | 
have  practically  eliminated  the  headache  from  my  case ;  \ 
and,  except  after  dark,  when  they  appear  to  have  a  con-  \ 
fusing  effect,  I  feel  that  they  have  assisted  me  greatly  in 
getting  about.  One  singular  and  to  me  unexplainable  re- 
sult of  wearing  them  is  the  development  of  a  partial  deaf- 
ness at  all  times,  and  quite  a  marked  obstruction  of  the 
hearing  after  dark,  especially  when  situated  amidst  a  con- 
fusion of  sounds.  Upon  the  whole,  I  have  made  quite  an 
appreciable  advance,  and  feel  greatly  encouraged.  I  am 
still  taking  forty-five  grains  of  bromide  daily.  Thanking  yoii 
heartily  for  the  interest  you  have  manifested,  and  assuring 
you  that  I  will  be  very  glad  to  write  to  you  fully  of  the 
development  of  any  new  symptoms, 

I  am,  etc. 

The  effort  of  inhibiting  his  convulsive  seizures  by  force 
of  will,  suggested  in  the  above  letter,  had  been  effectual  on 
several  occasions.  Once  he  had  the  premonitory  symptoms 
of  an  attack  (flushing  of  the  face  and  a  sense  cf  unusual 
fulness  of  the  head),  and  held  off  the  onset  for  several  min- 
utes, till  the  sudden  slamming  of  a  door  precipitated  it. 

These  seizures  varied  somewhat  in  their  character.  In 
several  of  those  observed  he  was  seen  to  raise  his  hand  to 
his  head  as  if  it  ached,  and  the  face  would  flush:  this 
warning  gave  him  time  to  sit  or  lie  down.  Immediately  fol- 
lowing this  there  was  a  clonic  convulsion  of  the  lower  jaw, 
and  a  peculiar  "  cry,"  which  diminished  with  the  intensity 
of  the  convulsion.  During  this  time,  which  was  about  a 
minute,  there  was  great  cyanosis  of  the  face  and  neck,  the 


i84 

superficial  veins  standing  out  prominently.  The  chin  was 
raised  and  the  head  retracted,  the  hands  clenched  and  arms 
half  flexed,  in  a  state  of  tonic  spasm.  Immediately  follow- 
ing the  convulsion  the  face  became  pale  and  the  head 
rested  back,  while  for  about  a  minute  he  appeared  semi- 
conscious, but  would  not  answer  questions.  After  some 
attacks,  unconsciousness  lasted  ten  or  fifteen  minutes. 

During  the  latter  part  of  1897  there  seemed  to  be  some 
improvement  under  bromide  treatment.  Then  the  convul- 
sive attacks  became  more  frequent,  severe  headaches  and 
vomiting  set  in,  and  the  pulse  gradually  grew  slower  (40  to 
50).     Finally,  coma  developed,  resulting  in  death. 

CXLVII. 

Nervous  Symptoms,    with    Attacks   of  Meiital  Distress   and 
Physical  Emotion-signs. 

A  young  married  man  of  twenty-three,  of  good  habits 
and  living  under  comfortable  circumstances,  came  complain- 
ing of  a  variety  of  nervous  symptoms,  and  gave  the  follow- 
ing history :  — 

He  had  always  been  of  nervous  temperament  even  from 
bo3'hood,  and  for  five  years  past  he  had  been  subject  to 
asthma.  At  times  his  digestion  had  been  poor.  His  worst 
suffering  was,  however,  '*  in  his  head."  He  felt  anxious,  con- 
fused, and  worried,  and  dreaded  insanity ;  and,  besides  this, 
there  were  actual  sensations  about  the  head  of  a  distressing 
character.  He  was  always  in  a  state  of  indecision,  and  this 
would  go  so  far  that  sometimes  at  night  he  would  take  his 
clothes  off  and  then  put  them  on  again  ;  while,  at  other  times, 
he  would  take  off  and  put  on  his  collar  and  cuffs,  without 
reason,  or,  again,  he  would  stand  before  the  looking-glass 
and  make  gestures  and  faces  at  himself.  Yet,  withal,  these 
acts  seemed  to  be  done  rather  from  a  lack  of  self-control 
than  from  any  strong  impulse.  He  says  he  is  very  forgetful, 
and  he  has  shown  many  symptoms  of  a  weak-minded  sort 


i85 

of  despondency  which  induces  him  to  lie  down  and  cry, 
without  cause.  He  was  a  weakly  boy,  and  never  accom- 
plished much  at  school,  although  he  is  fairly  intelligent,  and 
now  helps  more  or  less  to  carry  on  his  father's  business. 

It  was  learned  that  his  sister  died  four  years  ago,  and 
that  this  had  apparently  been  the  starting-point  of  an  in- 
crease in  severity  of  his  symptoms.  Again,  three  years 
ago,  he  had  the  ''grippe"  ;  and,  this,  too,  made  him  worse. 
Ever  since  that  period  onward  he  has  been  subject  to 
"  spells "  of  nervous  fear  and  excitement,  which  come  on 
him  at  various  times,  as,  for  example,  at  a  concert.  In 
these  spells  he  is  overcome  with  a  vague  sense  of  fear, 
confusion,  and  mental  distress  ;  and  with  it  his  face  gets 
flushed  and  his  heart  beats  violently  and  a  profuse  perspira- 
tion breaks  out.  He  does  not  like  to  read  the  newspapers 
on  account  of  a  sort  of  fear  which  is  set  up  in  his  mind  by 
seeing  accounts  of  mischances  to  others,  since  this  excites 
a  vague  anxiety  for  himself.  He  thinks  if  he  could  never 
see  a  newspaper  he  would  get  on  fairly  well.  He  is  very 
"  sensitive  "  to  the  opinions  of  others,  and  yet  sociable  and 
fond  of  company.  He  has  no  special  fear  of  high  places. 
At  times  he  has  been  very  hypochondriacal,  imagining  that 
he  should  experience  all  the  diseases  which  he  saw  or  heard 
of  as  affecting  any  one  else. 

He  has  been  married  about  two  years ;  and  for  the  first 
year  he  was  much  better,  but  later  grew  somewhat  irritable 
and  cross,  although  always  very  dependent  on  his  wife. 
Physical  fatigue  is  easily  excited  and  brings  on  pain  across 
the  hips,  besides  increasing  his  nervous  symptoms.  He 
frequently  passes  large  quantities  of  light-colored  urine,  and 
this  may  mark  a  sort  of  temporary  crisis  in  his  symptoms. 
The  eyesight  is  good,  but  reading  makes  him  nervous. 

The  top  of  the  head  is  tender,  so  that  even  brushing  the 
hair  lightly  is  unpleasant.  Close  inquiry  about  the  diges- 
tion indicates  that  he  suffers  from  excessive  acidity  in  the 
stomach.     Occasionally  this  troubles  him  so  much  that  he 


i86 

is  hysterical  and  nervous  until  he  can  induce  vomiting, 
after  which  he  feels  all  right.  Sometimes,  especially  when 
his  stomach  is  out  of  order,  he  has  visual  illusions,  the  ob- 
jects at  which  he  looks  seeming  to  advance  and  recede. 
At  other  times,  as  in  the  night,  he  has  a  feeling  as  if  his 
hands,  or  other  objects  or  parts  of  the  body,  were  growing 
larger.  In  the  morning  he  is  tired.  He  gets  out  of  breath 
on  exertion  ;  and,  under  excitement,  palpitation  of  the  heart 
comes  on,  as  well  as  flushing  of  the  face,  even  apart  from 
the  attacks  mentioned  above. 

Physical  examination  shows  a  fairly  nourished  but  excita- 
ble-looking person,  with  large  pupils  and  flushed  face.  The 
chest  has  the  form  known  as  pigeon-breasted,  and  the  mus- 
cular development  is  not  good.  There  is,  however,  no  dis- 
tinct disease  in  any  of  his  organs.  The  family  history  is  of 
interest  in  the  respect  that  three  of  his  four  brothers  and  his 
only  sister  are  distinctly  of  nervous  temperament,  and  that 
there  is  a  well-marked  history  of  tuberculosis  in  the  moth- 
er's family,  the  mother's  grandmother  and  four  of  her  uncles 
and  aunts  having  died  of  phthisis.  On  the  other  hand,  his 
father  and  mother  both  seem  to  be  free  from  marked  ner- 
vousness ;  and  the  father  has  conducted  a  large  business 
with  success. 

Although  this  patient  tried  many  treatments  without  re- 
ceiving much  benefit,  in  the  end  his  disease  took  a  turn  for 
the  better,  and  he  gradually  became  fairly  well. 

CXLVIII. 

General  Nervousness^  associated  with  a  sort  of  Tic. 

A  boy  of  nineteen  was  under  the  care  of  one  of  the 
writers,  off  and  on,  for  several  years,  on  account  of  general 
nervous  symptoms  which  prevented  him  from  applying  him- 
self to  any  mental  work.  He  had  never  been  robust,  but 
was  not  formerly  as  nervous  as  now.  He  used  to  have  a 
sort  of  tic  of  the  head,  which  lasted  for  a  long  time,  but 


187 

gradually  wore  away.  His  father,  who  was  a  man  of  good 
health,  but  of  no  great  education,  sent  the  boy  to  Harvard 
College;  but  he  found  himself  so  nervous  that  he  had  to 
give  up  his  course.  It  cost  him  a  great  effort  to  pass  the 
examinations;  and  this,  he  thought,  injured  him.  At  any 
rate,  he  took  to  his  bed  after  a  short  stay  at  Cambridge  ;  and 
his  father  had  to  take  him  home.  On  the  way  home  he  suf- 
fered much  from  severe  pain  in  the  abdomen,  and  could  not 
sleep  for  three  or  four  weeks  except  by  taking  hypnotics. 

He  suffers  from  a  feeling  of  great  physical  restlessness, 
which  he  can  relieve  for  an  instant  by  making  motions  with 
his  hands  and  feet,  though  only  to  find  himself  in  constant 
need  of  repeating  the  motion.  This  almost  irresistible  ten- 
dency to  make  motions  with  his  hands  and  feet  is  increased 
by  any  mental  or  physical  effort ;  and,  as  he  interprets  it,  the 
symptom  is  a  physical,  not  a  mental  one.  If  any  new  idea 
comes  into  his  mind,  he  feels  compelled  to  turn  it  over  a 
number  of  times,  repeating  each  time  the  same  course  of 
argument.  While  he  is  walking,  he  perpetually  carries  his 
right  hand  thrust  in  between  the  buttons  of  his  coat.  He 
has  no  fondness  for  physical  exercise  and  looks  unfit  for  it; 
for  his  pupils  are  large,  his  shoulders  stooping,  the  hands 
and  feet  cold,  the  heart  sounds  weak,  and  the  whole  nutri- 
tion poor.     Yet  he  has  no  active  mental  depression. 

This  young  man  was  treated  by  being  removed  from  home, 
and  placed  in  the  family  of  an  intelligent  young  physician 
and  his  wife.  This  admitted  a  certain  sort  of  discipline 
which  would  not  have  been  accepted  at  home ;  and  under 
this  influence  he  soon  improved,  though  it  was  thought  best- 
not  to  repeat  the  experiment  of  sending  him  to  college. 


i88 


CXLIX. 

Diffuse  Muscular  Rigidity^  lasting  Some    Weeks  and  passing 

away  slowly. 

A  boy  of  twelve,  with  personal  and  family  history  indicat- 
ing a  neuropathic  tendency,  came  to  the  hospital  complain- 
ing of  difficulty  in  opening  his  jaws  and  of  a  general  rigidity 
of  the  muscles  of  such  a  kind  as  to  make  walking  difficult. 
He  was  in  a  hysterical  sort  of  condition,  crying  sometimes 
without  obvious  cause  and  at  times  seeming  able  to  accom- 
plish small  feats  which  he  had  declared  to  be  impossible. 
There  was  also  a  slight  degree  of  mental  confusion,  which 
made  it  difficult  to  get  a  first-rate  history ;  but,  so  far  as  could 
be  learned,  he  had  been  well  until  about  four  days  before, 
when  he  was  knocked  down  by  a  severe  blow  on  the  chin 
while  he  was  playing  with  another  boy,  and  had  fallen  in 
such  a  way  that  his  knee  was  bruised. 

Two  days  after  the  accident  the  stiffness  of  the  jaws,  and 
a  rigidity  of  the  muscles  of  the  left  leg,  hip,  and  back, 
began  to  show  themselves,  preceded  by  restlessness;  and 
since  then  he  had  been  growing  gradually  stiffer.  When 
one  looked  at  him,  a  peculiar  expression  of  the  face  was 
seen,  a  sort  of  comical  mixture  of  smile  and  frown,  the  eye- 
brows being  contracted  and  the  muscles  of  the  mouth  being 
drawn  outward  and  upward.  The  jaws  could  be  opened 
voluntarily  about  one-sixteenth  of  an  inch,  and  passively  a 
little  more.  The  eyelids  w^ere  partly  closed.  His  gait  was 
scuffling,  the  left  leg  in  particular  being  dragged  as  he 
walked.  When  he  lay  upon  his  back,  there  was  notable 
arching  of  the  lumbar  vertebrae ;  and  the  position  soon  be- 
came irksome  to  him.  The  movements  of  the  legs  were 
slow,  and  all  the  muscles  felt  hard  and  tense.  The  degree 
of  this  rigidity,  however,  was  variable.  The  knee-jerks  were 
excessive,  but  there  was  no  ankle-clonus. 

The  temperature  at  the  first  examination  was  ioi°  F., 
but  afterward  continued  varying  from  90°  to  100°.  The 
arms  appeared  to  be  unaffected. 


Case  CXLIX. 


i89 

Several  diagnoses  were  suggested,  and  among  them  the 
suspicion  of  hysteria  was  raised.  This  explanation  seemed 
to  receive  some  support  from  the  fact  that  his  pain-sense 
was  a  good  deal  blunted,  so  that  a  pin  could  be  passed 
through  the  skin  of  the  forearm  on  either  side  without  ex- 
citing much  pain,  whereas  the  tactile  sense  was  practically 
normal. 

At  times  sudden  spasms  came  on,  generally  from  some 
external  stimulus  or  excitement ;  and  in  these  the  legs  were 
extended,  the  trunk  and  head  stiffened  and  bent  forward. 
This  attitude  corresponded  with  what  has  been  called 
orthothonos,  except  that  the  lordosis  continued  as  before. 
At  night  the  patient  would  sometimes  wake  suddenly  with  a 
scream  as  if  in  fear,  and  spasms  as  before  described  would 
come  on.  These  spasms  were  painful,  though  not  exceed- 
ingly so.  The  general  rigidity  of  the  muscles  diminished 
during  sleep,  but  did  not  wholly  disappear.  Even  the 
muscles  of  respiration  were  affected  somewhat,  so  that  the 
chest  was  as  if  encased  in  some  unyielding  substance.  The 
tissues  of  the  knee  which  had  been  bruised  were  excised 
and  carefully  examined  under  the  microscope,  but  nothing 
abnormal  was  found. 

The  boy  remained  in  this  condition  for  several  weeks  ;  but 
little  by  little  the  stiffness  of  the  muscles  grew  less,  and  he 
was  finally  discharged,  well. 

CL. 

Tendency  to  Spasms  of  the  Diaphragm  and  Limbs,  occurring 
under  Special  Conditions.     Recovery. 

A  woman,  thirty  years  old,  gave  a  history  of  having  been 
in  bed  fourteen  months  with  "  cerebro-spinal  meningitis," 
when  five  years  of  age.  At  ten  years  she  had  a  mild  attack 
of  chorea,  lasting  several  weeks.  Aside  from  this  her 
health  had  been  good  until  April,  1901,  when  her  sister  died 
of  phthisis.     This  brought  on  an  unusual  amount  of  mental 


depression,  but  still  she  kept  about  her  occupation  as  tele- 
phone operator. 

At  about  this  time  she  was  suddenly  seized,  while  at  work, 
with  a  "chill,"  in  which  her  teeth  chattered  and  she  shook 
all  over.  After  an  hour  the  severity  of  the  chill  diminished, 
and  she  was  able  to  go  home ;  but  some  general  trembling 
kept  up  for  two  days,  when  the  tremor  gave  place  to  spas- 
modic contractions  of  the  diaphragm,  occurring  more  or  less 
regularly  every  few  minutes.  These  contractions  were 
sometimes  associated  with  an  expiratory  grunt  or  bark. 
This  tendency  persisted  for  five  or  six  weeks,  and  then  sud- 
denly stopped  for  a  week,  but  started  up  more  violently 
than  ever  one  day  while  she  was  in  church.  On  this  occa- 
sion she  tried  so  hard  to  check  the  attack  that  she  fell  un- 
conscious, and  remained  so  for  two  hours.  There  were  no 
convulsive  movements  while  she  was  in  this  state. 

For  two  months  after  this  attack  she  had  only  occasional 
spasmodic  movements  while  about  the  house ;  but,  whenever 
she  went  out  on  the  street,  the  contractions  would  increase, 
and  she  would  fall  unconscious  and  remain  so  for  an  hour 
or  more.  This  kept  up  till  August,  and  since  then  she  has 
had  no  very  severe  attacks  ;  but,  whenever  she  goes  out  or 
becomes  startled,  she  is  seized  with  clonic  contractions  of 
the  diaphragm  and  abdominal  muscles,  and  these  contrac- 
tions involve  also  the  biceps  and  triceps,  if  she  is  under  ex- 
citement. While  in  this  state,  she  can  get  her  breath  only 
in  gasps,  and  her  speech  is  interrupted  and  jerky.  On 
being  left  alone,  she  becomes  quiet  almost  at  once. 

Examination  shows  the  pupils  to  be  very  large,  but  equal, 
and  to  react  normally  to  light.  The  cheeks  are  flushed. 
There  are  no  disturbances  in  sensibility.  The  knee-jerks 
are  normal.  Ankle-clonus  is  not  present.  Under  treat- 
ment the  trouble  became  corrected  in  two  to  three  weeks,  so 
that  even  very  severe  tests  caused  no  serious  return  of 
symptoms. 


191 


CLI. 

I£emi-an(Esthesia  of  Sudden   Onset,  with  Partial  Hemiplegia. 

A  teamster,  thirty-five  years  old,  came  to  the  hospital, 
saying  that  three  weeks  before,  on  rising  in  the  morning, 
he  had  found  his  whole  left  side  numb  and  prickly,  as  if 
"  asleep."  The  left  leg  also  was  weak,  though  he  was  able 
to  walk. 

On  examination,  besides  impairment  of  strength  of  the  left 
leg,  he  was  found  to  have  complete  left  hemi-anassthesia,  both 
for  touch  and  pain.  There  was  no  heminopsia,  and  the  eye- 
grounds  were  normal.  The  only  thing  in  his  personal  his- 
tory which  seemed  of  importance  was  that  he  had  syphilis 
three  years  previously,  which  had  been  treated  by  some 
physician  for  a  year. 

In  the  hospital  he  was  given  a  treatment  which  caused 
rapid  improvement ;  and  at  the  end  of  six  months  the  only 
symptom  left  was  a  subjective  numbness  of  the  left  foot, 
which  had  not  wholly  passed  away  at  the  end  of  a  year. 


CLII. 

Involuntary  Movements  of  the  Head  and  Face. 

In  November,  1901,  a  young  lady  of  twenty-one  came 
for  consultation  on  account  of  twitching  movements  of  the 
head  and  face,  which  had  annoyed  her  for  two  years.  The 
general  character  of  these  movements  were  such  as  might 
be  made  for  the  purpose  of  getting  rid  of  some  uncomfort- 
able sensation,  as  the  pressure  of  a  tight  collar,  or  the  like ; 
but,  in  fact,  she  was  unable  to  prevent  them  or  to  foresee 
their  occurrence.  They  came  with  greater  frequency  and 
force  when  she  was  tired,  but  she  was  never  wholly  without 
them  for  more  than  a  moment.  She  had  never  been  a  very 
strong  person,  though  lively  and  pleasant-tempered  and 
fond  of  social  pleasures. 


192 

A  year  before  these  particular  movements  began,  she 
broke  down  in  school  with  nervous  symptoms,  though  not 
doing  excessively  hard  work.  She  said  that  as  a  child  she 
had  bad  St.  Vitus's  dance ;  and,  in  fact,  on  close  ques- 
tioning, she  admitted  that  ever  since  that  period  she  had 
been  liable,  when  fatigued,  to  involuntary  movements, 
which  recalled,  on  the  one  hand,  those  which  she  had  had 
in  childhood  and,  on  the  other  hand,  those  which  she  had 
had  at  the  time  of  the  examination. 

Physical  examination  showed  a  systolic  murmur  at  the 
left  base,  but  otherwise  nothing  abnormal.  She  had  a 
bright  color  and  rather  excitable  manner.  Careful  tonic 
treatment — arsenic,  iron,  tonic-baths,  exercise,  and  rest  — 
helped  her  somewhat;  but  the  movements  still  persisted  at 
the  end  of  a  year. 

CLIII. 

Tendency  to  fall  to  the  Ground  ijuhen  Startled^  with  Altera- 
tion or  Loss  of  Co7isciousness. 

This  patient  is  a  married  woman  of  thirty,  American  by 
birth.  She  came  recently  to  the  hospital,  complaining  that 
on  slight  provocation,  as  when  startled  or  pushed,  her  legs 
would  give  way,  so  that  she  would  fall  to  the  ground,  while 
at  the  same  time  she  would  have  a  queer  feeling  in  the  pre- 
cordial region,  and  would  often  become  slightly  confused 
and  almost  lose  consciousness  for  a  moment.  Sometimes, 
indeed,  as  she  thinks,  she  entirely  loses  consciousness 
under  the  conditions  mentioned  above ;  but  she  never  has 
convulsions  and  never  bites  her  tongue.  These  attacks  do 
not  occur  at  night  nor  when  she  is  sitting  at  the  table. 

This  tendency  to  fall,  when  startled,  has  been  present 
ever  since  she  was  fourteen  years  old.  At  one  period  she 
would  fall  eight  to  ten  times  a  day.  At  this  time  she  had 
a  "  numbness  "  of  the  left  hand  and  arm,  and  for  a  time 
suffered  from  vomiting.  In  one  of  her  seizures  she  let  a 
kettle  of  hot  water  fall  out  of  her  hand  and  scalded  herself 


193 

badly,  and  even  now  she  often  bruises  herself  severely  in 
falling.  In  connection  with  these  attacks  she  has  such  a 
sense  of  uncertainty  and  fear  that,  as  she  walks  about  the 
room  or  goes  over  the  stairs,  she  steadies  herself  with 
her  hand,  just  as  a  healthy  person  might  who  was  climbing 
over  a  dangerous  place.  She  seems  fairly  intelligent,  but 
says  that  she  flies  easily  into  a  passion,  and  then  is  apt  to 
throw  things  at  her  husband.  She  suffers  from  recurrent 
dreams  of  unpleasant  character,  especially  if  at  all  tired ; 
and  this  she  is  very  apt  to  be,  as  she  has  but  little  endur- 
ance. Sometimes  this  sense  of  fatigue  comes  in  appar- 
ently causeless  waves,  which  are  dispelled  by  pleasant  or 
engrossing  occupations.  She  is  constipated,  but  the  appe- 
tite and  digestion  are  good.  The  menstruation  is  normal, 
but  she  has  had  neither  children  nor  miscarriages. 

She  was  a  nervous  child  ;  and,  when  seven  years  old,  after 
an  attack  of  scarlet  fever,  she  lay  in  bed  for  a  year,  "  unable 
to  move  hand  or  foot."  When  seventeen,  she  was  extremely 
anaemic. 

The  physical  examination  shows  that  the  knee-jerks  are 
very  lively,  and  associated  with  a  nervous  jerking  of  the 
whole  body,  and  that  the  middle  finger  of  the  left  hand  is 
analgesic,  so  that  a  pin  can  be  thrust  through  the  skin  with- 
out her  minding  it.  It  is  indeed  probable  that  the  whole 
left  side  is  slightly  deficient  in  sensibility. 

The  thoracic  and  abdominal  organs  are  in  a  healthy 
state,  so  far  as  can  be  determined  without  a  pelvic  exami- 
nation. 

Her  mother  is  said  to  have  had  a  similar  fear  of  falling 
and  to  have  suffered  from  migraine,  and  her  sister  died  of 
consumption. 


194 


CLIV. 

Constant  Involuntary  Movetnents  affecting  all  the  External 
Muscles  of  the  Body,  begiiining  in  Infancy  and  remaining 
without  Material  Change  through  life. 

An  infant,  previously  strong  and  vigorous,  was  seized, 
when  nine  months  old,  with  symptoms  for  which  no  cause 
could  be  assigned.  He  screamed  all  night,  and  in  the  morn- 
ing appeared  prostrated  and  helpless,  though  not  absolutely 
paralyzed.  As  he  regained  strength,  it  was  found  that  his 
movements  had  become  unsteady  and  awkward  ;  and,  as  time 
went  on,  this  tendency  became  more  striking.  The  charac- 
ter of  these  disordered  movements  could  be  best  studied 
when  the  child  was  old  enough  to  walk  and  talk  a  little,  and 
they  were  then  of  the  following  sort :  — 

When  he  tried  to  sit  still,  or  lay  reclining,  nothing  more 
would  be  seen  than  that  the  face  was  the  seat  of  grimaces 
of  varying  kinds,  and  that  the  limbs  could  not  be  entirely 
restrained  from  twisting  and  moving  slowly  in  various  direc- 
tions. When  he  tried  to  speak  or  to  execute  any  voluntary 
motion,  these  grimaces  and  contortions  became  greatly  ex- 
aggerated. The  involuntary  motions  were  not  quick  and 
shifting,  like  those  of  true  chorea,  but  always  rather  slow 
and  strong,  suggesting  a  pulling  of  the  limb  in  one  or  another 
direction  by  some  outside  force.  The  muscles  of  the  face 
and  tongue  were  so  strongly  affected  that  his  speech  was 
almost  unintelligible,  and  the  finer  movements  of  the  limbs 
were  likewise  impossible.  When  he  walked,  the  legs  were 
carried  stiffly,  yet  with  steps  of  varying  length,  as  if  he  was 
executing  a  sort  of  dance.  The  sensibility  was  wholly  un- 
affected. The  general  nutrition  was  perfect ;  and  the  mental 
condition  was  excellent  except  perhaps  for  a  slight  irritabil- 
ity, though  the  child  often  passed  for  an  imbecile  because 
he  found  so  much  difficulty  in  making  himself  understood. 

Years  of  persistent  training  improved  his  condition  to  a 
moderate  degree ;  and,  as  he  grew  up,  he  became  an  intelli- 


195 

gent  and  useful  member  of  society  in  spite  of  his  defects  of 
motion  and  speech.  In  the  attempts  to  overcome  the  dis- 
orderly movements  there  was  a  strong  instinctive  tendency 
to  throw  the  limbs  into  positions  of  complete  extension  or 
flexion,  in  which  they  could  be  maintained  by  a  gross  use  of 
force  without  the  necessity  of  balancing  the  antagonistic 
muscles.  This  assumption  of  fixed  positions  might  have  led 
to  deformities,  had  not  constant  exercise  been  used  to  pre- 
vent muscular  contractions. 

The  interest  of  this  case  may  be  increased  by  reference 
to  another  in  which  this  instinctive  tendency  to  prevent  dis- 
orderly movements  by  fixing  the  limb  in  a  definite  position 
by  powerful  muscular  spasm  had  gone  so  far  as  almost  to 
prevent  motion  altogether.  This  patient,  who  when  seen 
was  a  young  lady  of  eighteen,  was  wholly  unable  to  help 
herself  or  to  make  use  of  articulate  language.  She  was,  in 
fact,  almost  confined,  by  her  contracted  yet  heaving  muscles, 
to  a  position  of  complete  extension  on  a  couch,  and  was  un- 
able to  make  her  wants  known  except  by  inarticulate  sounds 
which  her  attendant  had  learned  to  understand.  It  might 
almost  be  said  that  she  had  practically  no  voluntary  control, 
except  over  the  eyes  and,  to  a  limited  degree,  the  head. 

CLV. 
Double  Athetosis. 

This  patient  was  a  little  boy,  who  at  the  time  of  his 
death  was  eight  years  old.  The  symptoms  of  his  disease 
had  been  present  in  some  measure  ever  since  birth,  and  con- 
sisted in  mobile  spasm,  essentially  like  that  described  in 
case  CLIV. 

He  had  been  unable  to  stand  alone  without  support,  and 
generally  kept  the  head  thrown  back  and  the  mouth  wide 
open,  though  without  drooling.  Besides  this,  he  had  suf- 
fered from  time  to  time  with  convulsions,  and  was  not  neat 
in  his  personal  habits.  His  intelligence  was  apparently  a 
good  deal  impaired. 


196 

The  father  of  this  child  had  had  a  syphilitic  infection  at 
one  period,  and  the  mother  had  had  three  miscarriages  after 
the  birth  of  this  child,  two  of  them  being  at  two  and  a  half 
months,  and  one  at  three  months.  Two  other  children  had 
also  been  born,  one  of  whom  died  with  diphtheria,  while  the 
other  is  living  and  well. 

The  child  whose  case  is  thus  briefly  reported  died  of  an 
intercurrent  affection ;  and  an  examination  was  made  five 
hours  afterward  with  the  result  that  no  gross  changes  of  any 
sort  were  found  either  in  the  bones,  membranes,  or  any  part 
of  the  brain,  pons,  or  medulla,  unless,  indeed,  an  unusual 
degree  of  paleness  may  be  considered  abnormal.  The 
specimen  was  unfortunately  lost  before  microscopic  ex- 
amination could  be  made  ;  but  a  most  careful  dissection  had 
failed  to  reveal  any  abnormality  either  of  the  convolutions, 
cortex,  blood-vessels,  or  any  portion  of  the  brain  substance. 

CLVr. 

Weakness  from  Birth,   Convulsions ;  Increasing  Rigidity 

of  the  Legs. 

This  patient  is  a  child,  five  years  old.  He  has  two 
older  brothers  and  a  younger  sister,  all  normal  and  healthy 
children.  His  mother  had  never  had  any  miscarriages. 
He  was  born  without  the  use  of  instruments,  after  a 
natural  and  easy  labor.  His  mother  noticed,  shortly  after 
birth,  that  his  head  was  small,  and  that  he  did  not  move  his 
arms  and  legs  around  as  her  other  children  had  done. 

At  the  age  of  eight  months  he  had  a  general  convulsion, 
lasting  ten  minutes,  and  this  was  followed  at  irregular  inter- 
vals by  many  more.  Sometimes  he  would  have  none  for  two 
or  three  weeks,  and  sometimes  they  would  come  every  day 
for  a  week  or  more.  On  one  occasion  the  convulsive  move- 
ments lasted  for  two  hours  continuously. 

When  he  was  two  years  old,  his  legs,  which  had  been  grow- 
ing rigid  for  some  time,  began  to  be  drawn  up  and  held 
more  and  more  tightly  together,  until  they  became  crossed. 


n 


n 

< 


197 

Physical  Examination. —  The  appearance  of  the  child  is 
that  of  a  ten  or  twelve  months  old  baby.  He  lies  on  his 
back,  rolling  his  head  from  side  to  side,  and  occasionally 
arching  the  back  and  retracting  the  head,  in  a  way  that  sug- 
gests the  opisthotonus  of  tetanus.  This  is  associated  with 
wrinkling  of  the  forehead  and  drawing  up  of  the  corners  of 
the  mouth. 

He  pays  very  little  heed  to  his  surroundings;  but,  if  a 
watch  is  held  in  front  of  him,  he  appears  to  notice  it  for  a 
moment.  Flies  crawl  over  his  face  and  gather  around  the 
margins  of  his  eyelids,  but  he  does  not  seem  to  be  dis- 
turbed by  them. 

The  head  is  small,  the  bi-temporal  diameter  being  mark- 
edly diminished. 

The  hair  is  sparse  and  fine,  and  grows  low  down  on  the 
forehead.  The  ears  are  rather  large  and  shell-like,  and 
stand  out  from  the  head.  The  eyes  are  expressionless, 
and  are  occasionally  pulled  sharply  to  the  right  or  left  or 
rolled  upward ;  and,  while  in  these  positions,  they  make 
coarse,  jerky  movements.  The  pupils  are  equal,  and  react 
to  light.     Moderate  strabismus  is  present. 

The  mouth  is  held  open  most  of  the  time,  and  saliva 
drools  from  the  corners. 

The  palate  is  very  high  and  rather  broad.  The  two  mid- 
dle incisors  of  the  upper  jaw  are  large ;  and  this  is  the 
more  noticeable  from  the  fact  that  the  adjacent  lateral  in- 
cisors are  hardly  visible,  suggesting  teeth  just  coming.  The 
other  teeth  are  even  and  rather  small. 

The  body  is  emaciated,  all  the  ribs  being  prominent,  and 
the  abdomen  markedly  retracted.  The  examination  of  the 
viscera  reveals  nothing  abnormal. 

The  arms  are  spastic,  and  are  held  close  to  the  body, 
flexed  at  the  elbow.  The  right  hand  is  flexed  at  the  wrist  with 
extended  fingers,  while  the  left  hand  is  extended  at  the 
wrist  with  flexed  fingers.  Both  hands  are  cold ;  and  the 
skin  is  blue,  mottled,  and  glossy. 


198 

The  right  leg  is  crossed  over  the  left,  at  about  the  middle 
of  the  thighs.  Both  legs  are  spastic,  with  marked  wasting 
of  all  the  muscles.  The  toes  are  held  in  a  position  of 
plantar  flexion.  The  skin  of  the  feet,  like  that  of  the  hands, 
is  blue,  cold,  and  glossy. 

The  movements  of  both  arms  and  legs  are  very  limited. 

The  knee-jerks  are  normal,  the  plantar  reflexes  absent. 
There  is  no  Babinsky  reflex,  and  no  clonus. 

The  child's  nurse  says  he  is  fed  only  with  difficulty.  He 
does  not  open  the  mouth  when  food  is  offered  ;  and  it  is 
necessary  to  hold  the  jaws  apart  by  force,  and  put  the  nour- 
ishment into  the  mouth  before  the  patient  makes  any  effort 
to  eat. 

CLVII. 

Morbid  Ideas. 

This  is  the  case  of  a  married  woman  of  forty-five,  who 
came  recently  for  advice  on  account  of  very  distressing 
morbid  ideas  from  which  she  cannot  free  herself  by  any 
effort  of  the  will.  They  take  many  forms,  but  the  principal 
one  is  a  haunting  dread  of  some  contamination  which  she 
fears  will  reach  her  through  her  food  or  by  contact  with 
some  contaminating  substance.  For  this  reason  she  washes 
her  hands  over  and  over  again,  many  times  a  day,  each 
time  finding  some  morbid  reason  for  doing  it,  which  she 
realizes  to  be  ridiculous. 

The  origin  of  the  trouble  seems  to  have  been  twofold. 
In  the  first  place,  as  a  child,  she  was  inclined  to  brood  over 
slight  troubles,  and  was  always  fastidious  about  matters  of 
personal  cleanliness.  Then,  twenty  years  ago,  just  after  her 
first  child  was  born,  her  husband  came  in  one  day  and  said 
he  had  been  bitten  by  a  dog.  The  idea  of  hydrophobia  im- 
mediately became  strongly  implanted  in  her  mind,  and  the 
more  so  because  she  had  always  been  afraid  of  dogs,  and 
because,  unfortunately,  she  had  read  some  newspaper  story 
of  a  laundress  who  was  said  to  have  been  inoculated  with 


199 

that  disease  through  washing  the  clothes  of  a  hydrophobic 
patient.  For  many  years  she  was  nearly  free  from  these 
tormenting  thoughts  ;  but  two  or  three  months  ago  they  took 
hold  of  her  with  renewed  force,  and  now  she  can  hardly  eat 
or  sleep,  especially  if  she  is  alone. 

There  is  a  continual  feeling  about  her  face  as  if  there  was 
some  moisture  there  which  she  must  wipe  away ;  but  this  is 
obviously  not  a  sensation  due  to  any  physical  cause,  but 
only  an  hallucination.  If  any  one  who  sits  opposite  her  in  a 
car  happens  to  be  reading  a  paper  and  gives  it  a  shake,  she 
immediately  becomes  extremely  nervous  lest  in  this  way  the 
infection  shall  have  been  transmitted  to  her  clothes  or  shoes. 

Her  bodily  health  is  good  in  all  respects  except  that 
through  worry  and  loss  of  sleep  and  food  she  has  become  a 
little  thin  and  pale. 

Careful  treatment  by  systematic  encouragement  and  sug- 
gestion have  failed  to  give  her  relief,  except  sometimes  for 
brief  periods.  It  has  been  necessary  to  provide  constant 
companionship  for  her,  and  she  has  been  advised  to  enter  a 
suitable  hospital. 

Her  father  and  sisters  are  persons  of  neuropathic  tem- 
perament. 

CLVIII. 

Syphilitic   Infection,  followed  by   Symptoms  of   very   General 

Character. 

In  December,  1894,  a  gentleman  was  sent  to  me  by 
another  physician  with  the  history  that  in  1890  he  had  had 
a  chancre  followed  by  mucous  patches  in  the  mouth  and 
perhaps  a  loss  of  hair.  He  was  under  treatment  and  obser- 
vation, at  that  time,  for  two  years  and  a  half,  during  which 
period  nothing  further  developed.  Moreover,  since  that 
time  he  has  been  under  the  care  of  several  different  physi- 
cians, all  of  whom  have  given  him  anti-specific  treatment  of 
one  or  another  sort. 

At  the  time  of  his  examination  he  was  complaining  of  a 


200 

variety  of  nervous  symptoms,  such  as  inability  to  sleep,  dull 
pains  in  the  back  of  th^  head  and  the  back,  sense  of  cd,d- 
ness  in  the  arms,  especially  the  Jeft,  numbneiss  and  prick- 
ling in  the  right  leg  and  foot,  and  dizziness. 

Careful  physical  examination  failed  to  reveal  anything 
abnormal,  though  the  patient  looked  pale  and  distressed. 
These  examinations  were  repeated  at  frequent  intervals  dur- 
ing the  next  few  years,  and  always  with  the  same  result. 
The  pupils,  the  knee-jerks,  and  the  handwriting  were  all 
normal ;  and  examination  of  the  heart,  arteries,  and  eye- 
grounds  gave  negative  findings.  Yet  the  patient  grew  more 
and  more  nervous,  and  came  back,  year  after  year,  in  the 
same  anxiety  and  with  the  same  symptoms. 

CLIX. 

Morbid  Fears, 

This  patient  is  a  man  of  forty-five,  English  by  birth  and  a 
carpenter  by  trade.  Although  a  strong  man  and  able  to  do 
a  hard  day's  work  without  fatigue,  he  suffers  greatly  from  a 
sense  of  fear  when  in  a  crowd,  as  at  church  or  in  a  crowded 
car  or  store.  This  feeling  of  fear  is  not  only  a  mental  dis- 
tress, but  is  accompanied  by  rapid  beating  of  the  heart,  and 
a  sense  of  "  goneness  "  referred  to  the  epigastrium,  which 
becomes  so  intense  that  he  fears  that  he  shall  actually  faint. 
He  has  also  been  troubled  lately  with  profuse  perspirations 
at  night,  coming  on  without  apparent  cause.  He  has  had 
these  symptons  for  many  years ;  and,  indeed,  even  as  a  boy 
he  used  to  faint  away  on  slight  provocation,  as  at  the  sight 
of  blood. 

When  quite  a  small  lad,  he  was  knocked  down  by  a  man, 
who  struck  him  a  heavy  blow  on  the  back  of  the  head.  He 
was  carried  home  unconscious,  and  this  was  always  thought 
by  his  family  to  have  been  the  cause  of  his  present  condi- 
tion. 

Four  years  ago  he  had  an  attack  of  dizziness  on  getting 
out  of  bed,  and  lost  consciousness. 


20I 

Physical  examination  showed  this  patient  to  be  a  strong, 
vigorous-looking  man,  though  bearing  the  signs  of  worry 
and  anxiety.  It  is  interesting  to  note  that  he  is  one  of  a 
family  of  ten  children,  most  of  whom  were  and  are  strong 
and  well.  One  brother,  however,  drank  heavily,  and  died  in 
an  asylum.  Except  for  this  he  declared  that  there  was  no 
neurotic  predisposition.  His  father  and  mother  were  both 
vigorous  people. 

CLX. 

Paralysis  of  Eye  Muscles ;  Mental  Failure.     Death. 

A  gentleman  of  forty-five,  unmarried,  presented  himself  in 
October,  1887,  mainly  on  account  of  double  vision,  due  ob- 
viously to  paresis  of  the  external  recti  muscles  of  the  left 
eye,  and  also  of  slight  dizziness.  There  was  no  headache 
nor  vomiting.  His  speech  had  become  slightly  thick,  sug- 
gesting that  of  a  person  under  the  influence  of  alcohol ;  and 
in  the  course  of  conversation  he  misused  words  to  some  ex- 
tent, though  this  he  had  not  himself  noticed.  He  charac- 
terized his  speech  defect  by  saying  that  his  tongue  "  seemed 
to  get  in  his  way,"  and  said  that  he  had  noticed  this  for 
some  months  past.  The  motions  of  the  tongue  were  rather 
slow,  and  were  associated  with  coarse  tremor.  There  was 
also  slight  paresis  of  the  lips.  The  pupils  responded  fairly 
to  light,  but  not  at  all  or  but  slightly  with  efforts  of  accom- 
modation. The  knee-jerks  were  less  than  usual,  and  the 
left  was  less  than  the  right.  The  fundus  of  the  eye  on 
either  side  was  normal.  There  was  no  tremor  of  the  hands, 
and  in  the  earlier  visits  no  mental  defect  was  detected.  He 
gave,  however,  the  history  of  specific  infection  twelve  years 
before,  not  followed  by  skin  eruptions,  and  was  consequently 
given  K  I  in  increasing  doses,  and  later  Unguentum 
Hydrarg.  Under  this  treatment  the  paralysis  of  the  eye 
muscles  steadily  improved,  and  the  double  vision  passed 
away.  His  speech  defect  also  became  less ;  but  it  was  at 
the  same  time  noticed  that  he  stumbled  over  his  alphabet 


202 

and  left  out  letters,  and  that  he  left  off  before  arriving  at  the 
end.  He  kept  on  with  his  business,  but  a  letter  written  on 
Jan.  iij  1888,  showed  defects  in  spelling  analogous  to  those 
observed  in  speech ;  that  is,  some  letters  were  left  out  and 
others  misplaced,  and  the  hand-writing  looked  careless. 

The  subsequent  history  of  the  case  will  be  given  at  the 
time  of  the  discussion. 

CLXI. 

Cerebral  Symptoms  of  Acute  Ofiset,  mdicating  rather   Wide- 
spread Disturbance. 

The  patient  was  a  man  of  forty-one.  When  he  was  first 
seen,  he  appeared  very  ill ;  and  his  friends  gave  the  follow- 
ing account  of  his  sickness  :  — 

For  five  months  past  he  had  not  been  thoroughly  well. 
There  had  been  no  symptoms,  at  first,  of  any  localized  dis- 
order ;  but  he  had  felt  "  mean  "  and  disinclined  for  business, 
and  with  more  or  less  headache.  After  three  months  of 
this  the  headache  began  suddenly  to  be  very  intense.  The 
pain  was  referred  to  the  forehead  over  the  lefL^yje,  and  ex- 
tended over  the  left  side  of  the  head,  especially  around  the 
ear.  There  was  no  fever,  but  a  few  days  later  the  tempera- 
ture was  100°  F.  On  the  third  day  his  speech  became  xyi- 
ceiigin  and  objects  were  mjs called.  The  next  day  he  was 
found  to  have  an  inua^ect  use  of  the  right  side  of  the  fage, 
as  shown  by  the  fact  that,  when  he  put  out  the  tongue,  the 
naso-labial  fold  of  the  left  side  became  more  prominent,  while 
that  of  the  right  side  was  partly  obliterated.  This  was  fol- 
lowed a  few  days  later  by  double  vision,  due  to  a  trifling  de- 
fect of  some  of  the  ocular  muscles. 

An  examination  made  a  few  days  after  this  showed  that, 
while  he  would  sometimes  answer  questions  accurately  and 
with  quite  a  long  sentence,  yet,  on  the  whole,  his  speech 
showed  marked  defgcj;  and  indicated  confusion  of  mind. 
Thus,  on  one  occasion  when  the  doctor  handed  him  a  pin,  ( 
/he  put  it  into  his  mouth  as  if  it  was  a  thermometer. 


203 

His  writing  was  confused,  like  his  speech.  The  headache 
continued  severe :  and  there  was  also  slight  fever,  but  no 
more  than  one  to  two  degrees  (taken  in  the  mouth).     The 

right  hand  and  arm  became  slightly w,eak,  and  there  was 

slight  drooping  of  the  left  eyelid.  The  knee-jerks  were 
diminished,  but  variable ;  and  a  slight  Babinsky  reflg^c  could 
occasionally  be  made  out  on  the  right  side.  An  ophthal- 
moscopic examination  showed  a  moderate  degree  of  papU- 
lids.  The  urine  showed  no  traces  of  albumen  or  sugar. 
The  pupils  were  responsive  to  light.  The  pulse  was  24  at 
the  first  examination,  and  not  especially  tense.  He  ad- 
mitted venereal  exposure,  but  denied  all  knowledge  of  infec- 
tion. There  had,  however,  been  urethritis  five  or  six  years 
before,  for  which  he  was  unable  to  account.  He  had  no 
children,  but  his  wife  had  had  one  miscarriageu 

The  treatment  which  was  instituted  in  accordance  with 

the  diagnosis  that  was  made  seemed  to  be  of  great  benefit, 

j  so  that  he  improved  rather  rapidly,  and  in  the  course  of  two 

months  he  was  nearly  restored  to  health  and  the  papillitis 

had  disappeared. 

Although  this  patient  had  never  been  absolutely  uncon- 
scious, yet  on  his  recovery  he  found  it  impossible  to  remem-i 
\  bar  anything  that  had  happened  during  the  two  weeks  of  his 
most  serious  symptoms. 

Three  months   after  his   apparent  recovery  he  had  two  , 
epileptiform    seizures,   although   the  treatment   which   had  ' 
/    benefited  him  at  first  had  been  continued  ever  since  with 
more  or  less  regularity. 

CLXH. 

Symptoms  suggesting  General  Paralysis  in  a  Patient  with 
Tumor  of  the  Corpus  Cullosum. 

This  case  is  that  of  a  gentleman  of  fifty,  with  a  good 
record  as  regards  health  and  mental  vigor,  except  that  he 
had  been  somewhat  liable  to  "  faint  turns,"  when  slightly 
ill  from  any  cause.     Three    or   four  years    before  his  first 


204 

visit  he  had  fallenjtojhe  ground  in  such  an_attack,  which 
was  brought  on  perhaps  by  diarrhoea. 

He  presented  himself  on  the  5th  of  August,  1898,  and 
then  stated  that  he  had  considered  himself  well  up  to  the 
middle  of  June  of  the  same  year,  when  he  was  taken  down 
with  what  he  called  "  nervous  prostration."  He  had  done 
business  up  to  June  29 ;  but  his  wife  stated,  in  response  to 
close  inquiry,  that  he  had  been  ''  rather  nervous"  for  two  or 
three  years,  and  more  irritable  than  formerly.  These  symp- 
toms had  been  worse  for  some  months,  and  had  been  as- 
sociated with  a  vague  sense  of  pressure  in  the  head  and 
eyes,  and  an  unusual  inclination  to  lie  down  and  rest.  On 
one  occasion  he  had  had  a  '' numbness  "  of  the  right  leg, 
which  lasted  a  day  or  two  and  then  passed  away.  This  had 
come  on  suddenly,  but  was  not  attended  with  loss  of  con- 
sciousness. It  also  appeared  that  his  mental  characteristics 
had  gradually  undergone  a  certain  amount  of  change,  of  a 
kind  which  suggested  the  possible  onset  of  general  paresis. 
For  the  past  six  months  he  had  felt  no  inclination  for  rec- 
reation of  any  sort.  Letter-writing  had  become  difficult ; 
and  he  frequently  repeated  himself  both  in  speech  and  on 
paper,  and  occasionally  left  out  words.  Throughout  the 
spring  he  had  been  troubled  about  slee£ing ;  and  partly  on 
this  account,  partly  because  he  found  it  more  and  more  dif- 
ficult to  work,  he  had  been  persuaded  to  go  on  a  trip  to  the 
Rangeley  Lakes.  There  he  at  first  improved  ;  but  after  a  few 
weeks  his  right  hand  became  l)a£etic  and  at  the  same  time 
his  speech  grew  somewhat  difficult,  although,  as  on  the  oc- 
casion when  the  leg  became  numb,  there  was  no  apoplectic 
seizure.  His  ability  to  collect  his  thoughts  had  continued 
to  fail,  and  his  mind  worked  slowly.  Both  legs  had  become 
somewhat  weak,  but  it  was  the  right  hand  that  mainly  gave 
him  trouble. 

On  physical  examination  he  was  found  to  be  an  intelli- 
gent-looking man,  though  but  little  inclined  to  take  part  in 
the    conversation  which  went    on    around    him,  either  with 


205 

word  or  expression  of  the  face.  His  s^geefih  was  hesitating 
and  stammering  in  a  high  degree.  He  was  unable  to  give 
the  name  of  the  town  and  country  where  he  had  stayed  for  a 
lono^  time  during  the  previous  month,  and  made  various  mis- 
takes in  telling  the  story  of  his  illness.  The  r^ht  hand  and 
right  side  of  the  face  were  paretic,  the  tongue  and  lips 
trembled.  The  knee-jerks  were  normal,  and  the  pupils  were 
equal  and  reacted  well  to  light.  The  tongue  was  coated, 
the  bodily  temperature  normal,  the  heart's  action  normal. 
In  spite  of  the  awkwardness  of  the  right  hand  he  was  able 
to  write  clearly  and  fairly  well,  but  omitted  letters  here  and 
there, a  sign  which  seemed  to  bear  out  the  notion  of  a  dif- 
fuse degeneration  of  the  brain  cortex.  Ophthalmoscopic  ex- 
amination  failed  at  that  time  to  r^eveal  any  si^   of  o^c 

neuritis. 

The  patient  was  not  seen  again  until  about  two  months 
later,  and  by  that  time  a  marked  change  had  taken  place  in 
his  condition.  He  was  then  suffering  from  unmistakable 
signs  of  bmm_tumor,— headache,  nausea,  vomiting,  optic 
neuritis,— and  besides  this  the  speech  had  become  slowei: 
and  more  hesjtating,  and  the  difficulty,  in  the  use  of  the 
right  hand  had  increased.  There  was  also  an  awkwardness 
of  both  legs,  so  that  he  toppled  over  twice  in  going  up- 
stairsniie  memory  was  considerably  impaired.  The 
knee-jerks  were  now  exaggerated. 

With  a  view  to  at  least  mitigating  the  effects  of  pressure 
the  patient  was  advised  to  enter  the  Massachusetts  General 
Hospital  for  operation.  Here  he  came  under  the  care  of 
Dr.  J.  C.  Warren,  who  on  November  8,  made  a  large  tre- 
phine opening  on  the  left  side  over  the  Rolandic  area,  but 
without  opening  the  dura,  which  was,  however,  found  to  be 
very  tense.  The  operation  was  done  under  chloroform,  but 
in  spite  of  this  precaution  the  shock  was  so  great  that  for 
several  hours  it  seemed  probable  that  the  patient  would  die. 
After  the  effects  of  this  shock  had  passed  away,  slight  im- 
provement began  to  show  itself,  both  as  regards  the  general 
symptoms,  the  speech,  and  the  use  of  the  limbs. 


2o6 

This  improvement  did  not  go  very  far,  however ;  and  after 
lingering  for  two  months,  practically  unable  to  speak  or  to 
help  himself,  though  not  actually  paralyzed,  and  in  a  con- 
dition of  considerable  mental  dulness  or  apathy  but  without 
pain  or  coma,  the  patient  died. 

At  the  autopsy  a  deep-seated  tumor  was  found,  which  im- 
pinged upon  the  corpus  callosum  in  its  whole  length,  and 
was  almost  confined  to  that  body  in  its  posterior  half. 

The  tumor  was  of  gliomatous  character. 

SThe  point  of  special  interest  in  this  case  is  the  early 
appearance  of  slight  changes  in  character  and  slight  impair- 
ment of  mental  power  and  of  memory,  coming  at  a  time 
when  neither  signs  of  focal  lesions  nor  of  general  pressure 
had  shown  themselves. 

The  very  early  occurrence  of  isolated  epileptic  seizures 
several  years  before  is  also  noteworthy,  because,  although  it 
is  not  easy  to  explain  them,  the  histories  of  several  other 
cases  report  similar  incidents. 

The  paralysis,  when  it  did  appear,  must  evidently  have 
been  due  to  pressure,  for  which  there  was  abundant  cause. 

CLXIII. 

Attack  of  Epileptic  Character^  terminating  rather  unexpectedly 
by  Rapid  Improvement  and  Recovery. 

I  was  called  one  day  to  see  a  patient  whose  name  and 
history  were  unknown  to  me,  with  the  request  to  come  in 
haste,  as  he  had  had  a  serious  apoplectic  attack.  On  reach- 
ing the  house,  I  found  a  middle-aged  man,  apparently  wholly 
unconscious,  perspiring  freely,  and  breathing  rapidly  and 
heavily,  his  face  red  and  his  cheeks  puffing  out  and  in  at 
each  breath.  The  limbs  were  all  relaxed,  right  and  left 
alike ;  but,  as  the  notes  are  given  from  memory,  I  cannot 
now  say  whether  the  cremaster  and  plantar  reflexes  of  the 
two  sides  were  different,  nor  whether  the  knee-jerks  were 
present  or  absent.  The  temperature  was  moderately  ele- 
vated, and  the  skin  hot  and  flushed. 


207 

His  condition  looked  very  serious ;  but,  in  view  of  the 
congested  condition  of  the  skin,  I  ordered  six  leeches,  to  be 
applied  on  the  temples.  This  was  done,  and  seemed  to 
bring  great  relief.  At  any  rate,  when  I  made  my  visit  the 
next  morning,  I  found  him,  to  my  surprise,  practically  well, 
with  but  few  traces  of  his  violent  symptoms  of  the  day  be- 
fore. I  then  made  further  inquiry  into  his  previous  history, 
and  found  that  his  memory  and  mental  powers,  and  also  his 
mental  balance,  had  been  failing  for  some  time  past,  and 
that  a  number  of  years  previously  he  had  had  signs  of 
syphilitic  infection. 

CLXIV. 

Blueness  of  Fingers^  with  Gangrene. 

A  woman  thirty-seven  years  old  had  been  through  a 
severe  attack  of  diphtheria  at  the  age  of  twenty-seven.  A 
few  weeks  after  her  recovery  from  this,  she  began  to  notice 
that  the  fingers  of  both  her  hands  would  become  blue  and 
cold  whenever  she  became  excited.  This  trouble  has  per- 
sisted ever  since  with  no  change,  except  that  it  is  more 
easily  brought  on  than  formerly.  She  says  that  her  fingers 
become  cold  and  blue,  and  feel  perfectly  lifeless  if  a  friend 
comes  in  to  call,  and  lately  this  same  tendency  has  mani- 
fested itself  in  her  toes. 

She  would  not  have  sought  advice  for  these  symptoms, 
however,  were  it  not  for  the  fact  that  during  the  past  week 
the  end  of  the  right  index  finger  has  become  gangrenous. 

Examination  of  the  hands  shows  all  the  fingers  to  be  very 
cold,  while  the  skin  is  blue  and  turgid.  This  condition  is  so 
marked  that  it  seems  almost  impossible  that  it  could  be  a 
temporary  one. 

The  fingers  are  held  in  a  half-flexed  position,  and  the 
patient  is  unable  to  fully  flex  or  extend  them,  though  she 
says  she  can  do  so  when  she  is  alone,  and  the  fingers  in  a 
more  natural  state.  The  terminal  phalanx  of  the  right  index 
finger  is  gangrenous. 


208 

The  tension  in  the  radial  arteries  is  normal,  as  taken  by  a 
tonometer. 

The  knee-jerks  are  very  lively,  though  there  is  no  ankle- 
clonus. 

CLXV. 

Pain  in  the  Hand  and  Arm^  with  Trophic  and  Vascular 
Changes  in  the  Fingers, 

A  lady  of  thirty-five,  unmarried,  came  complaining  of  pain 
in  the  right  arm,  of  one  year's  standing,  and  accompanied 
with  great  weakness.  This  had  begun  a  year  before,  in 
December.  It  had  been  first  felt  in  the  shoulder,  and  had 
then  spread  through  the  arm  and  into  the  fingers, —  especially 
the  first  two  fingers  and  the  thumb, —  and  also  into  the  pec- 
toral area.  Movements  increased  the  pain.  The  fact  of 
special  interest  in  the  case  had,  however,  been  the  occurrence 
of  vasomotor  signs  of  striking  character.  Near  the  beginning 
of  the  attack  the  forefinger  and  middle  finger,  and,  to  a  less 
degree,  the  third  and  fourth  fingers,  became  white  and  cold, 
and  remained  so  for  several  months.  As  the  circulation 
became  more  normal,  the  pain  in  the  fingers  grew  intense. 
The  epidermis  also  became  altered  and  thickened,  and  the 
whole  hand  swelled  and  was  at  times  burning  hot.  The  ends 
of  one  or  more  fingers  became  purplish,  suggesting  the  onset 
of  gangrene.  The  muscular  strength  of  the  fingers  became 
greatly  impaired.  The  whole  hand  and  arm  were  often  the 
seat  of  tingling  sensations,  and  this  could  be  brought  on  at 
any  time  by  pressure  above  the  clavicle.  Inquiry  into  the 
patient's  previous  history  showed  that  she  had  been  anaemic, 
and  that  many  years  before  she  had  had  a  cough  which 
lasted  a  year.  Inquiry  into  the  family  history  showed  a  lack 
of  vigor,  the  frequent  occurrence  of  catarrhal  affections,  and 
on  the  maternal  side  a  strong  tendency  to  tuberculosis. 


Case  CLXVI. 


209 


CLXVI. 

Hypertrophy  of  the  Head,  Face,  a7id  Extremities. 

This  patient  is  a  single  American  woman,  forty  years  old, 
who  had  had  no  illness  since  childhood.  The  catamenia 
stopped  at  the  age  of  thirty,  and  did  not  return  until  two 
months  ago.  Three  years  ago  she  had  severe  frontal  head- 
ache, most  of  the  time  during  a  period  of  six  months.  Two 
years  ago  she  had  some  pain  in  both  hips,  extending,  later, 
down  the  legs,  and  this  pain  was  aggravated  by  walking. 

About  a  year  ago  she  noticed  that  her  face  was  growing 
large,  especially  about  the  forehead  and  lower  jaw ;  and  it 
has  continued  to  grow  larger  ever  since.  Nine  months  ago 
her  feet  began  to  increase  in  size,  and  in  the  past  few 
months  she  has  had  difficulty  in  going  about  on  account  of 
weakness  of  the  legs.  It  has  been  impossible  lately  for  her 
to  get  shoes  large  enough  for  her  feet  without  having  them 
specially  made.  She  has  felt  well  except  for  general  weak- 
ness and  aching  pains  in  both  shoulders,  sometimes  radiat- 
ing down  the  arms ;  but  the  weakness  has  prevented  her 
from  doing  her  customary  housework  during  the  past  few 
weeks. 

Examination  shows  the  head  to  be  large  and  the  face 
massive,  the  lower  jaw  and  supra-orbital  ridges  being 
markedly  hypertrophied,  while  the  malar  bones,  instead  of 
being  prominent,  seem  rather  to  be  depressed.  The  tongue 
is  large  and  smooth.  The  pupils  are  equal,  and  react  to 
light,  and  examination  of  the  fundus  of  the  eyes  shows 
nothing  abnormal.  There  is  no  evidence  of  disturbance  of 
the  cranial  nerves.  The  bones  and  soft  tissues  of  the  hands 
and  feet  are  much  hypertrophied.  The  knee-jerks  are  equal. 
Motion  at  the  hip  and  shoulder  joints  is  limited,  and  accom- 
panied with  a  peculiar  crepitus.  The  thyroid  gland  is  not 
palpable.  For  several  months  past  there  has  been  no  ap- 
parent change  in  the  condition  of  the  face,  but  she  has  had 
an  occasional  return  of  her  old  headaches. 


2IO 

Examination  of  the  blood  and  urine  showed  nothing 
abnormal.     The  subsequent  history  has  not  been  learned. 

CLXVII. 
Deep^  Indolent  Ulcer  of  the  Toe. 

A  woman  forty-nine  years  of  age  had  an  attack  of 
"  rheumatism "  affecting  both  legs  when  she  was  thirty- 
seven.  The  pains  were  severe  and  hard  to  bear,  but  did 
not  keep  her  in  bed ;  and  she  does  not  remember  that  the 
joints  were  red  or  swollen.  Ever  since  this  attack  she  has 
been  subject  to  spells  of  sharp  shooting  pains  in  the  legs 
and  back,  which  last  a  few  days  at  a  time,  returning  at  in- 
tervals of  several  weeks. 

Aside  from  these  attacks  she  has  felt  perfectly  well  ever 
since  she  can  remember.  She  has  never  had  any  children 
nor  miscarriages,  though  she  has  been  married  over  twenty 
years. 

The  patient  now  seeks  medical  advice  regarding  a  sore 
on  the  ball  of  the  left  big  toe,  which  has  troubled  her  now 
for  eight  months.  It  does  not  pain  her  especially,  but  will 
not  heal  under  the  various  methods  of  treatment  she  has 
pursued. 

Examination  shows  the  skin  of  the  whole  left  foot  to  be 
cool  and  blue,  especially  the  big  toe ;  and,  in  addition,  this 
toe  shows  a  dry  ulcer,  the  size  of  a  dime,  on  the  under  sur- 
face. The  walking  is  not  much  interfered  with,  the  gait 
being  steady,  and  with  only  a  slight  limp. 

The  knee-jerk  is  normal  on  the  left  side,  but  very  slight  on 
the  right. 

The  right  pupil  is  larger  than  the  left,  and  both  are 
irregular  in  outline,  while  the  reaction  to  light  is  slow  in 
both  and  of  diminished  amplitude. 


Case  CLXVIII. 

(No.   I.) 


Case  CLXVIII. 

(No.    2.) 

Taken  six  weeks  after  No.i,  showing  result  of  treatment. 


211 


CLXVIII. 


Peculiar  Abnormality   of  Development.     Improvement    under 

Treatment. 

The  patient  is  a  girl  five  years  old.  On  account  of  pe- 
culiar circumstances  nothing  of  her  family  history  or  pre- 
vious symptoms  could  be  obtained.  It  was  learned,  how- 
ever, that  during  the  past  two  or  three  years  there  had  been 
no  noticeable  physical  nor  mental  development.  She  is  un- 
able to  walk  or  talk,  but  is  always  good-natured  and  smiling. 
She  takes  notice  of  bright  objects  held  before  her,  but  does 
not  play  with  toys.  She  has  never  learned  to  make  known 
her  desire  to  micturate  or  defecate. 

Examination  shows  a  child  with  marked  pallor  of  the  mu- 
cous membranes.  The  skin  is  dry  and  waxy ;  the  hair  is 
thin  and  dry  and  falls  easily.  The  head  is  large,  and  the 
face  is  full. 

The  features  suggest  that  the  child  is  a  boy  rather  than  a 
girl.  The  mouth  is  held  open,  and  the  broad  and  thick 
tongue  protrudes  from  it  most  of  the  time,  though  it  is  often 
withdrawn.  The  nose  is  broad  and  flat.  The  head  is 
thrown  back,  and  the  breathing  is  noisy,  as  if  in  conse- 
quence of  a  severe  cold  in  the  head.  There  are  large 
masses  of  fat  about  the  eyes,  neck,  and  shoulders,  and 
marked  pads  of  fat  are  seen  above  the  clavicles.  The  thy- 
roid gland  is  not  palpable. 

The  child  is  able  to  stand  if  she  supports  herself  by  a 
chair;  and  in  this  position  the  legs  are  abducted  and  the 
feet  turned  outward,  so  that  the  knees  point  in  almost 
opposite  directions.  The  legs  seem  short  in  comparison 
with  the  body,  which  gives  the  latter  an  impression  of  un- 
due length.  The  thighs  are  covered  with  thick  masses  and 
folds  of  fat. 

The  heart  examination  shows  a  loud  systolic  murmur  over 
the  whole  precordia,  loudest  over  the  pulmonic  area,  and 
transmitted   far    into    the   axilla.     The  pulmonic  second  is 


212 

accentuated.  There  is  no  evidence  of  cardiac  enlargement. 
The  blood  contains  25  per  cent.  Hgb.,  2,500,000  reds  and 
11,000  whites.  A  differential  count  shows  nothing  abnor- 
mal, more  than  is  compatible  with  the  anaemia. 

Marked  improvement  resulted  from  treatment,  as  is  shown 
by  the  photographs,  the  second  one  having  been  taken  six 
weeks  after  the  first. 

CLXIX. 

Debility^  with  a  Peculiar  Change  in  Nutrition^  coming  on  at 
the  Period  of  the  Menopause. 

A  fortune-teller  and  "  healer  of  diseases,"  about  sixty 
years  old,  had  passed  through  her  menopause  at  the  age  of 
forty-five.  In  her  early  life  she  had  always  been  active  and 
vigorous,  though  her  brother  and  sister  had  died  of  phthisis, 
and  her  father  and  mother  of  some  pulmonary  disease.  At 
the  time  that  her  catamenia  ceased  she  became  nervous 
and  irritable,  and  was  subject  to  "hot  flashes"  over  the 
body  and  in  the  head.  After  these  symptoms  had  lasted 
two  or  three  years,  she  began  to  grow  listless,  lost  her 
ambition,  and  felt  a  constant  sense  of  fatigue.  These  feel- 
ings of  listlessness  grew  worse  and  worse,  and  finally  be- 
came so  bad  that  for  five  years  past  she  sits  alone  in  her 
room  all  the  day  through,  and  does  not  care  to  go  out  to  see 
her  friends,  though  she  is  glad  to  have  them  visit  her.  She 
says  she  likes  to  be  alone  and  "  commune  with  the  spirits." 
Sometimes  she  sits  a  long  time  before  she  can  make  up  her 
mind  to  cross  the  room,  even  for  something  she  may  wish 
for  very  much.  She  has  recently  been  troubled  by  palpita- 
tion and  shortness  of  breath  on  exertion. 

She  says  she  has  been  growing  fatter  during  the  past  ten 
years,  and  thinks  that  her  face  shows  it  more  than  her  body. 
Her  memory  has  also  been  gradually  failing.  The  patient 
was  formerly  a  singer,  and  was  said  to  have  a  beautiful 
voice ;  but  now  it  has  grown  coarse  and  harsh,  and  after 
she  has  talked  ten  or  fifteen  minutes,  something  seems  to 


Case  CLXIX. 


Case  CLXIX. 


Case  CLXX. 


213 

close  in  her  throat,  so  that  she  is  unable  to  speak  aloud. 
Cold  weather  is  much  harder  to  bear  than  hot;  and  even 
in  summer  she  often  sits  near  the  stove  all  day,  trying  to 
keep  warm. 

The  patient  is  a  large  woman.  The  f-^ce  is  full,  and 
the  lines  of  expression  seem  to  be  obliterated  by  an  cede- 
matous  appearance,  but  there  is  no  pitting  on  pressure. 
The  hair  is  sparse  and  coarse,  and  comes  out  easily.  The 
skin  of  the  face  and  body  feels  dry  and  hard  The  pupils 
are  equal,  and  react  normally.  The  tongue  is  large  and 
moist,  and  the  teeth  poor.  The  voice  is  deep,  and  has  a 
rasping  quality,  while  the  speech  is  slow  and  measured. 
There  are  well-marked  pads  of  fat  above  the  clavicles.  The 
axillary  hair  is  wanting.  The  hands  are  large,  and  have  the 
appearance  of  being  very  cedematous,  though  here,  too,  there 
is  no  pitting.  The  heart  examination  shows  a  characteristic 
functional  murmur  in  the  pulmonic  area.  The  patellar  re- 
flexes are  normal.  The  thyroid  gland  is  not  palpable.  Ex- 
amination of  the  blood  shows  moderate  ana;mia.  The  urine 
is  normal. 

CLXX. 

Backward  Mental  and  Physical  Development.     Numerous 
Stigmata  of  Degeneratioji. 

This  case  is  given  to  be  con'rasted  with  No.  CLXVIII. 

The  patient  is  a  child  of  five  years,  of  Italian  parents. 
He  has  a  sister,  seven  years  old,  who  is  undeveloped  and 
has  never  learned  to  talk.  Two  younger  brothers  are  nor- 
mal and  healthy  children. 

He  has  never  shown  any  signs  of  intelligence  since  birth ; 
and  the  mother  says  he  is  always  cross  and  irritable,  and 
cries  most  of  the  time. 

The  back  is  covered  by  a  profuse  growth  of  long  fine 
hair.  The  head  is  peculiar  in  shape,  as  seen  in  the  illustra- 
tion, there  being  no  frontal  development,  so  that  a  straight 
line  can  be  drawn  from  the  tip  of  the  nose  nearly  to  the  ver- 


214 

tex.  There  is  marked  internal  strabismus  of  the  left  eye. 
The  ears  and  mouth  are  large,  and  the  palate  high  and 
narrow. 

The  body,  which  is  very  dirty,  emanates  a  strong  odor, 
suggesting  the  atmosphere  of  a  menagerie. 


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